GAO
November 2012
United States Government Accountability Office
Report to Congressional Committees
RECOVERING
SERVICEMEMBERS
AND VETERANS
Sustained Leadership
Attention and
Systematic Oversight
Needed to Resolve
Persistent Problems
Affecting Care and
Benefits
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GAO-13-5
November 2012
RECOVERING SERVICEMEMBERS AND
VETERANS
Highlights of GAO-13-5, a report to
congressional committees
Sustained Leadership Attention and Systematic
Oversight Needed to Resolve Persistent Problems
Affecting Care and Benefits
Why GAO Did This Study
What GAO Found
The National Defense Authorization
Act for Fiscal Year 2008 required DOD
and VA to jointly develop and
implement policy on the care,
management, and transition of
recovering servicemembers. It also
required GAO to report on DOD’s and
VA’s progress in addressing these
requirements. This report specifically
examines (1) the extent to which DOD
and VA have resolved persistent
problems facing recovering
servicemembers and veterans as they
navigate the recovery care continuum,
and (2) the reasons DOD and VA
leadership have not been able to fully
resolve any remaining problems. To
address these objectives, GAO visited
11 DOD and VA medical facilities
selected for population size and range
of available resources and met with
servicemembers and veterans to
identify problems they continue to face.
GAO also reviewed documents related
to specific DOD and VA programs that
assist recovering servicemembers and
veterans and interviewed the
leadership and staff of these programs
to determine why problems have not
been fully resolved.
Deficiencies exposed at Walter Reed Army Medical Center in 2007 served as a
catalyst compelling the Departments of Defense (DOD) and Veterans Affairs
(VA) to address a host of problems for wounded, ill, and injured servicemembers
and veterans as they navigate through the recovery care continuum. This
continuum extends from acute medical treatment and stabilization, through
rehabilitation to reintegration, either back to active duty or to the civilian
community as a veteran. In spite of 5 years of departmental efforts, recovering
servicemembers and veterans are still facing problems with this process and may
not be getting the services they need. Key departmental efforts included the
creation or modification of various care coordination and case management
programs, including the military services’ wounded warrior programs. However,
these programs are not always accessible to those who need them due to the
inconsistent methods, such as referrals, used to identify potentially eligible
servicemembers, as well as inconsistent eligibility criteria across the military
services’ wounded warrior programs. The departments also jointly established an
integrated disability evaluation system to expedite the delivery of benefits to
servicemembers. However, processing times for disability determinations under
the new system have increased since 2007, resulting in lengthy wait times that
limit servicemembers’ ability to plan for their future. Finally, despite years of
incremental efforts, DOD and VA have yet to develop sufficient capabilities for
electronically sharing complete health records, which potentially delays
servicemembers’ receipt of coordinated care and benefits as they transition from
DOD’s to VA’s health care system.
What GAO Recommends
GAO recommends that DOD provide
central oversight of the military
services’ wounded warrior programs
and that DOD and VA sustain highlevel leadership attention and
collaboration to fully resolve identified
problems. DOD partially concurred with
the recommendation for central
oversight of the wounded warrior
programs, citing issues with common
eligibility criteria and systematic
monitoring. DOD and VA both
concurred with the recommendation for
sustained leadership attention.
View GAO-13-5. For more information, contact
Randall B. Williamson at (202) 512-7114 or
williamsonr@gao.gov.
Collectively, a lack of leadership, oversight, resources, and collaboration has
contributed to the departments’ inability to fully resolve problems facing
recovering servicemembers and veterans. Initially, departmental leadership
exhibited focus and commitment—through the Senior Oversight Committee—to
addressing problems related to case management and care coordination,
disability evaluation systems, and data sharing between DOD and VA. However,
the committee’s oversight waned over time, and in January 2012, it was merged
with the VA/DOD Joint Executive Council. Whether this council—which has
primarily focused on long-term strategic planning—can effectively address the
shorter-term policy focused issues once managed by the Senior Oversight
Committee remains to be seen. Furthermore, DOD does not provide central
oversight of the military services’ wounded warrior programs, preventing it from
determining how well these programs are working across the department.
However, despite these shortcomings, the departments continue to take steps to
resolve identified problems, such as increasing the number of staff involved with
the electronic sharing of health records and the integrated disability evaluation
process. Additionally, while the departments’ previous attempts to collaborate on
how to resolve case management and care coordination problems have largely
been unsuccessful, a joint task force established in May 2012 is focused on
resolving long-standing areas of disagreement between VA, DOD, and the
military services. However, without more robust oversight and military service
compliance, consistent implementation of policies that result in more effective
case management and care coordination programs may be unattainable.
United States Government Accountability Office
Contents
Letter
1
Background
DOD and VA Have Not Fully Resolved Persistent Problems with
Case Management and Care Coordination, Disability Evaluation
Systems, and Electronic Sharing of Health Records
DOD and VA Have Not Fully Resolved Long-standing Problems
Due to Deficiencies in Leadership and Oversight, Resources, and
Collaboration
Conclusions
Recommendations for Executive Action
Agency Comments and Our Evaluation
26
44
45
46
Enrollment and Populations for Select Department of Defense and
Department of Veterans Affairs Programs
54
Medical Category Assignment Process for Care Coordination
Programs
77
Appendix III
Comments from the Department of Defense
79
Appendix IV
Comments from the Department of Veterans Affairs
85
Appendix V
GAO Contact and Staff Acknowledgments
92
Appendix I
Appendix II
Related GAO Products
6
15
93
Tables
Table 1: Military Services’ Wounded Warrior Programs: Types of
Services Provided
Table 2: Eligibility Criteria for Military Services’ Wounded Warrior
Programs
Page i
13
19
GAO-13-5 Recovering Servicemembers and Veterans
Table 3: Military Services’ Wounded Warrior Program Efforts to
Measure Program Performance
Table 4: Military Services’ Wounded Warrior Programs: Enrollment
for Fiscal Year 2011
Table 5: Army Warrior Care and Transition Program Enrollment
Populations and Characteristics, Fiscal Years 2008 through
2011
Table 6: Army Wounded Warrior Program Enrollment Populations
and Characteristics, Fiscal Years 2008 through 2011
Table 7: Navy Safe Harbor Program Enrollment Populations and
Characteristics, Fiscal Years 2008 through 2011
Table 8: Air Force Wounded Warrior Program Enrollment
Populations and Characteristics, Fiscal Years 2008 through
2011
Table 9: Air Force Recovery Care Program Enrollment Populations
and Characteristics, Fiscal Years 2008 through 2011
Table 10: Marine Corps Wounded Warrior Regiment Enrollment
Populations and Characteristics, Fiscal Years 2008 through
2011
Table 11: United States Special Operations Command’s Care
Coalition Enrollment Populations and Characteristics,
Fiscal Years 2008 through 2011
Table 12: Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn (OEF/OIF/OND) Care Management
Program Enrollment Populations and Characteristics,
Fiscal Years 2008 through 2011
Table 13: Federal Recovery Coordination Program (FRCP)
Enrollment Populations and Characteristics, Fiscal Years
2008 through 2011
Table 14: Referral Information Routinely Tracked by DOD and VA
Case Management and Care Coordination Programs
33
55
58
60
62
64
65
67
69
71
73
75
Figures
Figure 1: Timeline of Key Events in the 2-Year Period Following the
Walter Reed Army Medical Center Media Reports
Figure 2: Original Senior Oversight Committee Organizational
Chart, including the Lines of Action (LOA) Workgroups
Figure 3: The Department of Defense’s Vision of the Assignment
Process for the Recovery Coordination Program and the
Federal Recovery Coordination Program
Page ii
8
9
78
GAO-13-5 Recovering Servicemembers and Veterans
Abbreviations
DOD
Dole-Shalala Commission
FRCP
IDES
LOA
MTF
NDAA 2008
OEF
OIF
OND
PTSD
RCP
Recovering Warrior Task Force
Senior Oversight Committee
TBI
VA
VAMC
WWCTP
Department of Defense
President’s Commission on Care for
America’s Returning Wounded
Warriors
Federal Recovery Coordination
Program
Integrated disability evaluation system
Line of Action
military treatment facility
National Defense Authorization Act for
Fiscal Year 2008
Operation Enduring Freedom
Operation Iraqi Freedom
Operation New Dawn
posttraumatic stress disorder
Recovery Coordination Program
Department of Defense Task Force on
the Care, Management, and
Transition of Recovering Wounded,
Ill, and Injured Members of the
Armed Forces
Wounded, Ill, and Injured Senior
Oversight Committee
traumatic brain injury
Department of Veterans Affairs
Department of Veterans Affairs Medical
Center
Office of Wounded Warrior Care and
Transition Policy
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GAO-13-5 Recovering Servicemembers and Veterans
United States Government Accountability Office
Washington, DC 20548
November 16, 2012
Congressional Committees
A series of media reports in early 2007 disclosed troublesome
deficiencies in the provision of outpatient services at Walter Reed Army
Medical Center in Washington, D.C. 1 These reports prompted broader
questions about whether the Departments of Defense (DOD) and
Veterans Affairs (VA) were fully prepared to meet the needs of the
growing number of servicemembers and veterans returning from recent
conflicts. Several review groups were subsequently tasked with
investigating the reported problems and identifying recommendations. 2
These groups identified common areas of concern including: inadequate
case management to ensure continuity of care, 3 confusing disability
evaluation systems, and insufficient sharing of servicemembers’ health
records and other data between DOD and VA—all long-standing
problems that we have reported on extensively. 4
To elevate the response to concerns raised by these review groups, DOD
and VA established the Wounded, Ill, and Injured Senior Oversight
Committee (Senior Oversight Committee) in May 2007. The committee
was intended to operate on a short-term basis to review and implement
1
“Soldiers Face Neglect, Frustration at Army’s Top Medical Facility,” Washington Post
(Washington, D.C.: Feb. 18, 2007); “The Other Walter Reed: The Hotel Aftermath,”
Washington Post (Washington, D.C.: Feb. 19, 2007); and “Hospital Investigates Former
Aid Chief,” Washington Post (Washington, D.C.: Feb. 20, 2007).
2
Independent Review Group, Rebuilding the Trust: Report on Rehabilitative Care and
Administrative Processes at Walter Reed Army Medical Center and National Naval
Medical Center (Arlington, Va.: April 2007); Task Force on Returning Global War on Terror
Heroes, Report to the President (April 2007); President’s Commission on Care for
America’s Returning Wounded Warriors, Serve, Support, Simplify (July 2007); Veterans’
Disability Benefits Commission, Honoring the Call to Duty: Veterans’ Disability Benefits in
the 21st Century (October 2007); and Department of Defense Office of the Inspector
General, Department of Veterans Affairs Office of the Inspector General, DOD/VA Care
Transition Process for Service Members Injured in OIF/OEF (June 2008).
3
According to the Case Management Society of America, case management is defined as
a collaborative process of assessment, planning, facilitation, and advocacy for options and
services to meet an individual’s health needs through communication and available
resources to promote high quality, cost-effective outcomes.
4
See list of related GAO products at the end of this report.
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GAO-13-5 Recovering Servicemembers and Veterans
the recommendations made by the various review groups and improve
seamlessness in the provision of care for recovering servicemembers and
veterans. 5 It was cochaired by the Deputy Secretaries of Defense and
Veterans Affairs and included the military service Secretaries and other
high-ranking officials within the departments. Congress subsequently
passed the National Defense Authorization Act for Fiscal Year 2008
(NDAA 2008) requiring the Secretary of Defense and the Secretary of
Veterans Affairs to jointly develop and implement policy, to the extent
feasible, to improve the care, management, and transition of recovering
servicemembers. 6 Because of its related ongoing work, the Senior
Oversight Committee also assumed responsibility for addressing these
requirements.
Despite actions taken by DOD and VA to address the problems identified
at Walter Reed in 2007, concerns remain that recovering servicemembers
and veterans continue to face many of the same problems as they did in
2007 navigating the recovery care continuum, from acute medical
treatment and stabilization, through rehabilitation, to reintegration—either
back to active duty or to the civilian community as a veteran. In 2009,
Congress required DOD to establish a task force to assess the
effectiveness of DOD programs and policies developed to assist
recovering servicemembers and to make recommendations for
continuous improvements of such policies and programs. 7 The DOD Task
Force on the Care, Management, and Transition of Recovering Wounded,
Ill, and Injured Members of the Armed Forces—referred to as the
Recovering Warrior Task Force—issued its first report in September
2011; 8 it contained 21 recommendations on a variety of issues affecting
recovering servicemembers. 9 Additionally, congressional committees held
5
In this report, we will use the term “recovering servicemembers” to denote wounded, ill,
and injured servicemembers.
6
Pub. L. No. 110-181, § 1611, 122 Stat. 3, 433 (2008).
7
National Defense Authorization Act for Fiscal Year 2010, Pub. L. No. 111-84, § 724,
123 Stat. 2190, 2389 (2009).
8
Department of Defense Task Force on the Care, Management, and Transition of
Recovering Wounded, Ill, and Injured Members of the Armed Forces, Department of
Defense Recovering Warrior Task Force 2010-2011 Annual Report (September 2011).
9
To understand how VA interacts with servicemembers, the Recovering Warrior Task
Force reviewed VA programs, including those that assist servicemembers with the
transition from DOD’s to VA’s health care system.
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GAO-13-5 Recovering Servicemembers and Veterans
multiple hearings in 2010 and 2011 that highlighted ongoing difficulties
facing these servicemembers and veterans, including issues with
duplication and poor coordination among case management and care
coordination programs, 10 delays in completing the disability evaluation
process, and the lack of full interoperability between DOD’s and VA’s
computer systems. 11
The NDAA 2008 required that we report on DOD’s and VA’s progress in
developing and implementing joint policy on issues related to the care,
management, and transition of recovering servicemembers. 12 As
discussed with the committees of jurisdiction, we have reviewed and
reported on the departments’ progress with respect to various topic areas.
This review, which is focused on the continuity of care for recovering
servicemembers and veterans, is the latest in our body of work. 13 In this
review, we are reporting on
1. the extent to which DOD and VA have resolved persistent problems
facing recovering servicemembers and veterans as they navigate the
recovery care continuum and
2. the reasons DOD and VA leadership have not been able to fully
resolve any remaining problems.
10
According to the National Coalition on Care Coordination, care coordination is a clientcentered, assessment-based interdisciplinary approach to integrating health care and
social support services in which an individual’s needs and preferences are assessed, a
comprehensive care plan is developed, and services are managed and monitored by an
identified care coordinator.
11
See Hearing on the Federal Recovery Coordination Program: From Concept to Reality,
Subcommittee on Health, Committee on Veterans’ Affairs, House of Representatives
(May 13, 2011); and Review of the VA and DOD Integrated Disability Evaluation System,
Hearing before the Committee on Veterans’ Affairs, United States Senate (Nov. 18, 2010).
12
Pub. L. No. 110-181, § 1615(d), 122 Stat. 2, 447.
13
GAO has produced a body of work assessing progress made to improve care,
management, and transition of recovering servicemembers, including: Recovering
Servicemembers: DOD and VA Have Made Progress to Jointly Develop Required Polices
but Additional Challenges Remain, GAO-09-540T (Washington, D.C.: Apr. 29, 2009);
Recovering Servicemembers: DOD and VA Have Jointly Developed the Majority of
Required Policies but Challenges Remain, GAO-09-728 (Washington, D.C.: July 8, 2009);
DOD and VA Health Care: Federal Recovery Coordination Program Continues to Expand
but Faces Significant Challenges, GAO-11-250 (Washington, D.C.: Mar. 23, 2011); DOD
and VA Health Care: Action Needed to Strengthen Integration across Care Coordination
and Case Management Programs, GAO-12-129T (Washington, D.C.: Oct. 6, 2011).
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GAO-13-5 Recovering Servicemembers and Veterans
To respond to these objectives, we interviewed the directors of the
following case management and care coordination programs, 14 including
•
the Army Warrior Care and Transition Command’s Warrior Transition
Units and the Army Wounded Warrior Program,
•
the Navy Safe Harbor Program,
•
the Air Force Recovery Care Program and the Air Force Wounded
Warrior Program,
•
the Marine Corps Wounded Warrior Regiment,
•
the United States Special Operations Command’s Care Coalition,
•
the Federal Recovery Coordination Program, and
•
VA’s Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn (OEF/OIF/OND) Care Management Program.
We collected data for each of these programs, such as the number of
enrollees over time. (See app. I for data on enrollment and population
characteristics for these programs.) We also reviewed documents
describing the scope, mission, and leadership of these selected
programs.
In addition, we took the following steps to determine the extent to which
DOD and VA have resolved persistent problems affecting recovering
servicemembers and veterans along the recovery care continuum:
•
We visited a judgmental sample of 11 DOD military treatment facilities
(MTF) and VA Medical Centers (VAMC) to identify variations in how
care coordination and case management programs are being
operated at the local level. We focused on Army and Marine Corps
MTFs because, collectively, the wounded warrior programs for these
military services serve more than 70 percent of the wounded, ill, and
injured servicemember and veteran population. We selected facilities
14
We selected key care coordination and case management programs that provide
assistance to recovering servicemembers and veterans—many of which were created or
modified after Walter Reed media reports. These programs have also been the subject of
prior reviews by GAO and others.
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GAO-13-5 Recovering Servicemembers and Veterans
that provide or have access to significant medical and rehabilitation
resources as well as facilities that have fewer medical or rehabilitation
resources. The sites we visited included MTFs at Fort Bragg (N.C.),
Fort Knox (Ky.), Fort Carson (Colo.), Fort Belvoir (Va.), Fort Meade
(Md.), Walter Reed National Military Medical Center (Md.), Camp
Lejeune (N.C.), and Quantico (Va.), and VAMCs in Richmond,
Virginia; Denver, Colorado; and the District of Columbia. At these
facilities, we met with local leadership officials and the officials
responsible for managing the facilities’ case management and care
coordination programs, and we obtained information on how these
programs were working as well as the types of problems that
recovering servicemembers and veterans continue to face. While at
these facilities, we met with recovering servicemembers and veterans
to obtain information about their experiences.
•
We interviewed officials from military and veteran advocacy groups to
obtain their members’ perspective on any problems that persist in
navigating the recovery care continuum.
•
We interviewed the director of the VA Liaison for Healthcare Program
to understand VA’s role in assisting recovering servicemembers’
transition from DOD’s to VA’s health care system.
•
We met with members of the Recovering Warrior Task Force,
reviewed relevant task force documentation, and attended its public
meetings to obtain information about problems they identified that
affect recovering servicemembers and veterans.
•
We reviewed published and ongoing studies and GAO reports 15
describing problems that recovering servicemembers and veterans
face, including issues related to the disability evaluation system and
the electronic sharing of health records between DOD and VA.
To identify the reasons why DOD and VA leadership have not fully
resolved any remaining problems facing recovering servicemembers and
veterans, we reviewed relevant documentation to identify the roles of
DOD and VA offices that coordinate or oversee case management or
care coordination programs, their placement within their respective
departments, and whether and how these offices monitor the
15
See list of related GAO products.
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GAO-13-5 Recovering Servicemembers and Veterans
performance of the programs we reviewed. We also obtained information
about organizational and program changes, including officials’ views
about the potential impact of these changes. We also interviewed key
DOD and VA leadership officials, such as the Deputy Assistant Secretary
of Defense for Wounded Warrior Care and Transition Policy, VA’s Chief
of Staff, and former and current officials from the departments’
coordinating and oversight offices, including the Senior Oversight
Committee, DOD’s Office of Wounded Warrior Care and Transition
Policy, the Interagency Program Office, and the VA/DOD Collaboration
Service, which is an office within VA. To obtain information about recent
efforts DOD and VA have initiated to address problems facing
servicemembers and veterans, we interviewed DOD and VA officials
participating in these activities, including officials involved in the DOD and
VA Warrior Care and Coordination Taskforce. We also reviewed the
documentation available regarding the departments’ recent efforts;
however, we predominately relied on testimonial evidence provided by
these officials.
The NDAA 2008 also requires us to certify whether we had timely access
to sufficient information to make informed judgments on the matters
covered by our report. We were provided sufficient information in a timely
manner to assess the extent to which DOD and VA have resolved
persistent problems facing recovering servicemembers and veterans as
they navigate the recovery care continuum and the reasons DOD and VA
leadership have not been able to fully resolve any remaining problems.
We conducted this performance audit from July 2011 through September
2012 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit to
obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our findings
and conclusions based on our audit objectives.
Background
Review groups identified significant problems after the media reports
concerning Walter Reed. Initial efforts to respond to these problems were
primarily coordinated through the Senior Oversight Committee, and DOD
and VA undertook additional efforts to respond to these problems.
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GAO-13-5 Recovering Servicemembers and Veterans
Review Groups Identified
Problems across the
Recovery Care Continuum
Following the revelations at Walter Reed, several review groups noted
significant problems that may arise during servicemembers’ recovery from
wounds, illnesses, and injuries. 16 Some of these problems involve the
provision of appropriate medical care, while others involve the acquisition
of needed DOD and VA benefits. In 2007, one of the review groups, the
President’s Commission on Care for America’s Returning Wounded
Warriors—commonly referred to as the Dole-Shalala Commission—noted
that recovering servicemembers depend on the effective and efficient
provision of medical services and benefits across the recovery care
continuum, 17 which is separated into three phases:
•
recovery, when wounded, ill, and injured servicemembers are
stabilized and receive acute inpatient medical treatment at an MTF,
VAMC, or private medical facility;
•
rehabilitation, when recovering servicemembers with complex trauma,
such as missing limbs, receive medical and rehabilitative care; and
•
reintegration, when servicemembers either return to active duty or to
the civilian community as veterans.
A recovering servicemember or veteran may not experience the recovery
care continuum as a linear process, and may move back and forth across
the continuum over time, depending on his or her medical needs. For
example, a servicemember who has transitioned to the rehabilitation
phase may go back to the recovery phase if there is a need to return to
an MTF to obtain acute medical care, such as a surgical procedure.
Initial Efforts to Address
Problems Were
Coordinated by the Senior
Oversight Committee
DOD and VA took a number of steps to address the problems identified
by the review groups that investigated the issues raised by the Walter
Reed media reports. As an initial step, the departments established the
16
The terms “wounded, ill, and injured” are used by DOD and VA as general
classifications of servicemembers or veterans with regard to their medical condition.
“Wounded” generally means any injury inflicted by an external force during combat. “Ill
and injured” refers to any illness or injury in the line of duty that may render the
servicemember medically unfit to perform the duties of his or her office, grade, rank, or
rating.
17
President’s Commission on Care for America’s Returning Wounded Warriors, Serve,
Support, Simplify.
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GAO-13-5 Recovering Servicemembers and Veterans
Senior Oversight Committee to coordinate and oversee DOD’s and VA’s
efforts to jointly resolve these problems. Through this committee, DOD
and VA created programs and initiatives to assist recovering
servicemembers and veterans as they navigate the recovery care
continuum. Key efforts included the establishment of the integrated
disability evaluation system (IDES), the Federal Recovery Coordination
Program (FRCP), the Recovery Coordination Program (RCP), and the
Interagency Program Office. (See fig. 1.)
Figure 1: Timeline of Key Events in the 2-Year Period Following the Walter Reed Army Medical Center Media Reports
a
Several review groups, including the Dole-Shalala Commission, were tasked with investigating the
problems reported at Walter Reed Army Medical Center in Washington, D.C., and identifying
recommendations. The other review groups included the Independent Review Group, Rebuilding the
Trust: Report on Rehabilitative Care and Administrative Processes at Walter Reed Army Medical
Center and National Naval Medical Center (Arlington, Va.: April 2007); Task Force on Returning
Global War on Terror Heroes, Report to the President (April 2007); Veterans’ Disability Benefits
Commission, Honoring the Call to Duty: Veterans’ Disability Benefits in the 21st Century (October
2007); and Department of Defense Office of the Inspector General, Department of Veterans Affairs
Office of the Inspector General, DOD/VA Care Transition Process for Service Members Injured in
OIF/OEF (June 2008).
Senior Oversight Committee. The Senior Oversight Committee was
responsible for ensuring that the recommendations—which totaled more
than 600 from the various review groups—were properly reviewed,
coordinated, implemented, and resourced. Supporting the Senior
Oversight Committee was an Overarching Integrated Product Team, the
membership of which included the Assistant Secretaries of Defense, the
military departments’ Assistant Secretaries for Manpower and Reserve
Affairs, and various senior officials from DOD and VA. This team
coordinated, integrated, and synchronized the work of the eight “Lines of
Action” (LOA) that focused on specific issues, including case
management, disability evaluation systems, and data sharing between
DOD and VA. (See fig. 2.)
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GAO-13-5 Recovering Servicemembers and Veterans
Figure 2: Original Senior Oversight Committee Organizational Chart, including the Lines of Action (LOA) Workgroups
Each LOA included representation from DOD, including each military
service, and VA. They performed the bulk of the work to address the
issues and recommendations of the various review groups, including
establishing plans, setting and tracking milestones, and identifying and
enacting early and short-term solutions. More specifically, the LOAs were
as follows:
•
LOA 1—Disability Evaluation: Responsible for addressing efforts to
reform the DOD and VA disability evaluation systems.
•
LOA 2—Traumatic Brain Injury (TBI)/Post Traumatic Stress Disorder
(PTSD): Responsible for addressing issues related to TBI/PTSD.
•
LOA 3—Case Management: Responsible for addressing issues
related to the care, management, and transition of recovering
servicemembers from recovery to rehabilitation and reintegration.
•
LOA 4—DOD/VA Data Sharing: Responsible for addressing issues
regarding the electronic exchange of DOD and VA health records.
•
LOA 5—Facilities: Responsible for addressing issues relating to
military and VA medical facilities.
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GAO-13-5 Recovering Servicemembers and Veterans
•
LOA 6—”Clean Sheet” Review: Developed recommendations to
improve care and benefits without the constraints of existing laws,
regulations, organizational roles, personnel constraints, or budgets.
•
LOA 7—Legislation and Public Affairs: Responsible for addressing
legal and other issues for policy development.
•
LOA 8—Personnel, Pay, and Financial Support: Responsible for
addressing compensation and benefit issues.
Some of the key efforts initiated out of the LOAs included the
establishment of an integrated disability evaluation system, care
coordination programs, and steps towards the electronic exchange of
DOD and VA health records—a responsibility that was later assumed by
the Interagency Program Office.
DOD/VA Integrated Disability Evaluation System. Through LOA 1, DOD
and VA jointly began to develop and pilot IDES to improve the disability
evaluation process by eliminating duplication in DOD’s and VA’s separate
evaluation systems and expediting the receipt of VA benefits. Specifically,
IDES merges DOD’s and VA’s separate medical exams for
servicemembers into a single exam process; consolidates DOD’s and
VA’s separate disability rating decisions into a single VA rating decision;
and provides staff to perform outreach and nonclinical case management
and explain VA results and processes to servicemembers. By October
2011, DOD and VA had fully deployed IDES at 139 MTFs in the United
States and several other countries.
Care Coordination Programs. LOA 3 took the lead role in addressing
problems with uncoordinated case management for recovering
servicemembers and veterans through the establishment of two care
coordination programs—the FRCP and the RCP. The FRCP was based
on a recommendation from the Dole-Shalala Commission that a single
individual—a recovery coordinator—would work with existing DOD and
VA case managers to ensure that servicemembers had the resources
needed for their care. LOA 3 designed the FRCP to assist “severely”
wounded, ill, and injured OEF and OIF 18 servicemembers, veterans, and
18
OEF, which began in October 2001, supports combat operations in Afghanistan and
other locations, and OIF, which began in March 2003, supports combat operations in Iraq
and other locations. Since September 1, 2010, OIF is referred to as Operation New Dawn
(OND).
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their families with access to care, services, and benefits. This population
includes servicemembers and veterans who suffer from traumatic brain
injuries, amputations, burns, spinal cord injuries, visual impairment, and
PTSD. The program uses federal recovery coordinators to monitor and
coordinate clinical services, including facilitating and coordinating medical
appointments, and nonclinical services, such as providing assistance with
obtaining financial benefits or special accommodations, needed by
program enrollees and their families. Federal recovery coordinators, who
are senior-level registered nurses and licensed clinical social workers,
were intended to serve as the single point of contact among all of the
case managers of DOD, VA, and other governmental and
nongovernmental programs 19 that provide services directly to
servicemembers and veterans. Although the FRCP was designed as a
joint program, it is administered by VA, and the federal recovery
coordinators are VA employees.
LOA 3 subsequently developed the RCP in response to a requirement in
the NDAA 2008. The RCP is a DOD-specific program that uses recovery
care coordinators to coordinate nonclinical services and resources for
“seriously” wounded, ill, and injured servicemembers who may return to
active duty, unlike those categorized as “severely” wounded, ill, and
injured, who are not likely to return to duty and would be served by the
FRCP. The military services were responsible for separately
implementing the RCP through each of their existing wounded warrior
programs as a means of providing care coordination services to program
enrollees.
Electronic Sharing of Health Records. LOA 4 was focused on addressing
issues related to the electronic exchange of DOD and VA health records.
However, this effort was superseded by the NDAA 2008, 20 which required
the establishment of the Interagency Program Office to serve as a single
point of accountability for both departments in the development and
implementation of interoperable electronic health records. 21 Although
DOD and VA retained the responsibility for the development and
19
Federal Recovery Coordinators are intended to coordinate all care and benefits for their
enrollees, including coordinating assistance from private sector programs.
20
Pub. L. No. 110-181, § 1635, 122 Stat. 3, 460-63.
21
Interoperability is the ability of two or more systems or components to exchange
information and to use the information that has been exchanged.
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management of the information technology systems, the Interagency
Program Office was responsible for ensuring the implementation of an
electronic health records system or capabilities that allowed for the
complete sharing of health care information for the provision of clinical
care. In October 2011, the Interagency Program Office also became
accountable for DOD’s and VA’s work on developing an integrated
electronic health records system that both departments would use for
their beneficiaries.
Additional Efforts by DOD
and VA to Address
Problems Facing
Recovering
Servicemembers and
Veterans
In addition to the Senior Oversight Committee’s efforts, DOD, its military
services, and VA developed or modified a number of programs and
initiatives to assist recovering servicemembers and veterans in navigating
the recovery care continuum.
Military Services’ Wounded Warrior Programs. The military services’
wounded warrior programs were established to assist recovering
servicemembers 22 during their recovery, rehabilitation, and initial
reintegration back to active duty or to civilian life. Most of these programs
provide nonclinical case management services to the recovering
servicemembers; that is, they help to resolve issues related to finances,
benefits and compensation, administrative and personnel paperwork,
housing, and transportation. In addition, the wounded warrior programs
serve as the central point of access to other types of services or
resources that support recovering servicemembers, such as clinical case
management, care coordination, and career, education, and readiness
services. (See table 1.) If a wounded warrior program does not directly
provide a service or resource, it can facilitate servicemembers’ access to
that service or resource. Although the wounded warrior programs were
intended mainly to provide services to recovering servicemembers, all but
one of the programs continue to assist individuals after they have
transitioned to veteran status.
22
Recovering servicemembers include those who are wounded, ill, or injured in a combat
zone or due to an incident that occurred in the United States or overseas while in active
status.
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Table 1: Military Services’ Wounded Warrior Programs: Types of Services Provided
Types of services provided
Military services’ wounded
warrior program
Clinical case
management
Nonclinical case
management


Care
coordination
Career,
education, and
a
readiness
Army
Army Warrior Care and Transition
Program: Warrior Transition Units and
Community-Based Warrior Transition
b
Units

Army Warrior Care and Transition
Program: Army Wounded Warrior
Program












Navy/Coast Guard
Navy Safe Harbor Program
Air Force
Air Force Wounded Warrior Program


Air Force Recovery Care Program
Marine Corps
Marine Corps Wounded Warrior
Regiment
United States Special Operations Command
United States Special Operations
Command’s Care Coalition
Source: GAO analysis of military services’ wounded warrior program information.
Notes: The characteristics listed in this table are general characteristics of each program; individual
circumstances may affect the services provided by specific programs. For the purposes of this report,
clinical case management services include services such as scheduling medical appointments and
providing outreach education about medical conditions such as PTSD. Nonclinical case management
services include services such as assisting servicemembers with financial benefits and accessing
accommodations for families.
a
Career, education, and readiness services are provided through programs such as the Warrior
Athlete Reconditioning Program and DOD’s Operation Warfighter Program and Education and
Employment Initiative. The Warrior Athlete Reconditioning Program enhances recovery by engaging
wounded, ill, and injured servicemembers in individualized physical and cognitive activities outside of
traditional therapy settings. Operation Warfighter is a federal internship program for wounded, ill, and
injured servicemembers that places them in supportive work settings to prepare them to return to
active duty or to transition into jobs in the government or private sector. To access the Operation
Warfighter Program a recovering servicemember has to be enrolled in a military service wounded
warrior program. In addition, the military services’ wounded warrior programs facilitate access to other
programs such as the Warrior Athlete Reconditioning Program.
b
A warrior transition unit is technically an Army brigade, battalion, or company that provides command
and control, administrative support, primary care and case management and other services to
support soldiers and their families during recovery, rehabilitation, and transition back to active duty or
to civilian life. For the purposes of this report, we are categorizing it as a wounded warrior program.
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VA Transition Programs. VA’s Liaison for Healthcare Program and its
OEF/OIF/OND Care Management Program assist recovering
servicemembers with transitioning from DOD’s to VA’s health care
system. As of August 2012, the Liaison for Healthcare Program employed
33 liaisons at 18 MTFs nationwide. 23 After a DOD or VA treatment team
determines that a recovering servicemember is medically ready to
transition to a VAMC, a VA liaison facilitates the transfer from an MTF to
a VAMC closest to their homes or to the most appropriate locations for
the specialized services their medical condition requires. VA liaisons
follow recovering servicemembers as they enter the VA health care
system, ensuring that their first VA appointments are scheduled.
Thereafter, the VA OEF/OIF/OND Care Management Program team
assigned to each recovering individual coordinates the individual’s care at
the VAMC and provides ongoing follow-up. 24 Each VAMC has an
OEF/OIF/OND Care Management Program team in place to coordinate
patient care activities.
23
According to a VA official, in fiscal year 2013, VA will hire 10 additional liaisons and
expand the number of MTFs where liaisons will be located to 21.
24
The VA OEF/OIF/OND Care Management Program screens all returning combat
veterans to determine if case management services are required.
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DOD and VA Have
Not Fully Resolved
Persistent Problems
with Case
Management and Care
Coordination,
Disability Evaluation
Systems, and
Electronic Sharing of
Health Records
Recovering
Servicemembers and
Veterans Do Not Always
Have Access to the Case
Management and Care
Coordination Programs
Designed to Assist Them
Recovering servicemembers’ access to case management and care
coordination programs has been impeded by two main factors—(1) the
limited ability to identify and refer those servicemembers who could
benefit from enrollment in the programs along with officials’ reluctance to
refer them, and (2) variations in eligibility criteria among the military
services’ wounded warrior programs, resulting in access disparities for
similarly situated recovering servicemembers. 25
Recovering Servicemembers
Are Not Always Identified and
Referred to Programs That May
Benefit Them
We found that referrals may be lacking or delayed (1) from military
service unit commanders to wounded warrior programs; (2) from
wounded warrior programs to the FRCP; and (3) for certain groups of
servicemembers, such as those with “invisible injuries” as well as
members of the National Guard and Reserve.
Referral to the military services’ wounded warrior programs. The military
services’ wounded warrior programs primarily use referrals to identify
recovering servicemembers that might be eligible for enrollment.
However, we found that the methods for referral, which include casualty
reports and direct referrals, are imprecise, such that all servicemembers
25
Not all wounded, ill, and injured servicemembers and veterans are eligible for access to
these programs. Most military service wounded warrior programs only serve those who
are “seriously” and “severely” wounded, ill, and injured.
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who could benefit from being enrolled in these programs are not
necessarily identified and referred.
Officials from three wounded warrior programs told us that casualty
reports are the primary method for receiving referrals. 26 Casualty reports
are initial alerts to military personnel, including wounded warrior program
officials, that a servicemember has been injured. These reports can be
initiated by unit commands or other military personnel as a method of
referral to the wounded warrior programs. However, wounded warrior
program officials from four wounded warrior programs told us that
casualty reports are not created after every injury or may be created late
in a servicemember’s recovery. In particular, some of these officials said
that military service unit command staff may delay or not create casualty
reports for servicemembers not injured in combat, such as for injuries that
occur stateside or while on leave, because servicemembers’ units may
not find out about such incidents immediately.
According to wounded warrior program officials, referrals to wounded
warrior programs also can be made directly from unit command staff and
other sources, including staff at the MTF where a recovering
servicemember is receiving treatment or through self-referrals. 27 These
referrals also may not be made in a timely manner. Specifically, unit
command staff may not refer potentially eligible servicemembers to
wounded warrior programs because either they want to “take care of their
own” or because they are not well informed about the programs and the
services they provide, according to wounded warrior program officials.
For example, a wounded warrior program official told us that he identified
a servicemember who had sustained a gunshot wound to the head but
was still assigned to his combat unit. This official explained that even
though the servicemember was receiving treatment, he could have
benefited from being enrolled in the wounded warrior program because of
the additional assistance it provides, including nonclinical case
management and care coordination services. Additionally, several
recovering servicemembers told us that they encountered difficulties in
26
Casualty reports, including personnel casualty reports, are electronic messages that
contain casualty information including type of injury, where the injury occurred, and
location of the injured servicemember.
27
We found that referrals by unit command staff are most likely, because they have the
most knowledge about servicemembers’ conditions, injuries, and treatment locations.
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their recovery as a result of staying in their units and not being referred to
a wounded warrior program earlier. For example, a recovering
servicemember told us that despite having been recently discharged from
a hospital for arm injuries, he was required to operate a floor buffing
machine in his unit, which was difficult for him as a result of his injuries.
He did not receive rehabilitative treatment for his injuries until he was
assigned to a wounded warrior program. Furthermore, we found that most
of the military services’ wounded warrior programs do not always track
the number of referrals to their programs, including data on whether or
not servicemembers referred to the programs were actually enrolled. (See
table 14 in app. I for additional information about referral data.) Without
this information, it is not clear whether all those who could benefit from a
wounded warrior program are being enrolled.
Referral to the FRCP. In addition to problems with referrals to wounded
warrior programs, wounded warrior program officials sometimes delay or
fail to make referrals of potentially eligible servicemembers to the FRCP,
which coordinates care across the departments and throughout the
recovery care continuum. As we have previously reported, the FRCP
relies predominantly on referrals from other sources, including wounded
warrior program officials and clinical treatment teams, because it does not
have a systematic way to identify potential enrollees. 28 Referrals to the
FRCP are important because federal recovery coordinators are intended
to provide continuity of care throughout servicemembers’ recovery,
starting with their initial treatment at an MTF and throughout the recovery
care continuum. They can also assist in facilitating recovering
servicemembers’ access to VA services and benefits while
servicemembers are still on active duty, according to VA officials. 29
However, we found that officials from wounded warrior programs view the
jointly created and established FRCP as a VA program and, therefore,
delay their referrals until it is certain that the servicemember will become
a veteran.
Referrals for certain servicemember populations. We found that certain
servicemember populations may be at greater risk for not being identified
for DOD and VA case management and care coordination programs.
28
GAO-11-250.
29
Servicemembers are eligible for certain VA benefits while still on active duty, including
access to treatment at specialized VA facilities and grants for home and car modifications.
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Specifically, according to wounded warrior program officials,
servicemembers who have undiagnosed, “invisible” wounds, such as
PTSD and TBI, may be at greater risk of not being referred to a wounded
warrior program or the FRCP until it becomes apparent that the
servicemember cannot be deployed. For example, a servicemember told
us that although he was experiencing anxiety every time he put on his
uniform, it was not until he had a severe anxiety attack, as a result of his
PTSD, that he was hospitalized and then referred to a wounded warrior
program. According to officials representing military advocacy
organizations, National Guard and Reserve servicemembers may be
particularly reluctant to identify injuries and illnesses because they are
eager to return home and do not want to be delayed at the installation for
an evaluation of any conditions they may have. However, these officials
said that when these servicemembers have been deactivated and
problems manifest themselves later on, they may experience difficulties
establishing that their injuries or illnesses are a result of their service in
the military, which could make it difficult for them to access services and
programs provided by DOD and VA.
Recovering Servicemembers’
Access to the Military Services’
Wounded Warrior Programs Is
Likely to Be Inequitable Due to
Variations in Their Eligibility
Criteria
Because of variations in eligibility criteria among the military services’
wounded warrior programs, DOD cannot assure that similarly situated
servicemembers have equitable access to these programs, leading to
disparities in the level of assistance provided across the military services.
(See table 2.) For example, servicemembers can only be eligible for the
Air Force Wounded Warrior Program if they have a combat-related injury
or illness, whereas servicemembers with combat or non-combat-related
injuries or illnesses can be eligible for the Army’s Warrior Transition Units.
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Table 2: Eligibility Criteria for Military Services’ Wounded Warrior Programs
Military services’ wounded warrior program
Eligibility criteria
Army
Army Warrior Care and Transition Program:
Warrior Transition Units and Community-Based
Warrior Transition Units
Serves servicemembers who require at least 6 months of rehabilitative care
a
and complex medical management
Army Warrior Care and Transition Program:
Army Wounded Warrior Program
Serves “severely” wounded, ill, and injured servicemembers in the warrior
transition units who have, or are expected to receive, a physical evaluation
b
disability rating of 30 percent or greater in one or more specific categories or a
combined rating of 50 percent or greater for conditions that are combat-related
Navy/Coast Guard
Navy Safe Harbor Program
Serves “seriously” wounded, ill, and injured sailors and coast guardsmen not
likely to return to duty in 180 days and likely to be medically retired, as well as
high-risk wounded, ill, and injured sailors that have less serious health
concerns
Air Force
Air Force Wounded Warrior Program
Serves servicemembers with a combat-related injury or illness that requires
c
long-term care as well as examinations to determine fitness for duty
Air Force Recovery Care Program
Serves all servicemembers who are “seriously” ill and injured either in a
combat-related incident or in a non-combat-related incident
d
Marine Corps
Marine Corps Wounded Warrior Regiment
Serves wounded, ill, and injured servicemembers who require more than 90
days of medical treatment or rehabilitation. A recovering servicemember also
may be assigned to the Wounded Warrior Regiment when:
•
the unit command cannot support transportation requirements to the
military treatment facility,
•
the Marine cannot serve a function in the unit command due to his/her
injuries or illness, or
•
the Marine has three or more medical appointments per week.
United States Special Operations Command
United States Special Operations Command’s
Care Coalition
Assists Special Forces servicemembers who are
•
wounded, injured, or ill evacuated from a combat area;
•
wounded, injured, or ill returned to duty or redeployed; or
•
injured or ill whose injury or illness is not combat-related.
Source: GAO analysis of military services’ wounded warrior program information.
a
Reservists in need of definitive medical treatment for conditions caused or aggravated while on
active duty or training status are also eligible.
b
After medical examinations are conducted to determine a servicemember’s ability to continue to
serve in the military, decisions are made about the servicemember’s fitness for duty and about a
servicemember’s disability rating, which determines the DOD and VA benefits he or she can receive.
c
According to an Air Force Wounded Warrior Program official, the program does not define long-term
care or provide criteria related to the time needed for recovery.
d
According to an Air Force Recovery Care Program official, a servicemember is designated as
“seriously’ ill or injured on the basis of a medical diagnosis made by Air Force medical staff when
referred to the program; the program does not make this designation.
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As a result of these differences in eligibility criteria, recovering
servicemembers in one military service may qualify for entry in their
wounded warrior program while similarly situated servicemembers in
another military service do not have access to their program.
Consequently, according to wounded warrior program officials, some
recovering servicemembers do not have access to services that would
otherwise be available to them, including the RCP and Operation
Warfighter. 30 Additionally, because wounded warrior programs facilitate
access to other programs and services, including the VA Liaison for
Healthcare Program and the Warrior Athlete Reconditioning Program, 31
not being eligible for a particular wounded warrior program could preclude
a servicemember from receiving the services of these other programs. 32
Military coalition officials who advocate for recovering servicemembers
and their families told us the lack of standardization across similar
programs, such as the military services’ wounded warrior programs, is
one of the main reasons recovering servicemembers “fall through the
cracks” or do not get the services that they need when they are
navigating the recovery care continuum.
DOD is aware of inconsistencies in eligibility criteria among the military
services’ wounded warrior programs and the potential for disparities in the
provision of services and assistance that may result. DOD has not taken
action to correct this, however, despite the identification of this issue as a
potential problem for recovering servicemembers by a congressionally
mandated DOD task force. Specifically, in its 2011 annual report to
30
Operation Warfighter is a DOD-sponsored internship program for wounded, ill, and
injured servicemembers who are at MTFs. Operation Warfighter is designed to provide
recuperating servicemembers with meaningful activity outside of the hospital environment
that assists in their wellness and offers a formal means of transition back to the civilian
workforce. Open to active duty, National Guard and Reserve components, Operation
Warfighter represents an opportunity for servicemembers in a medical hold status to build
their resumes, explore employment interests, develop job skills, and gain valuable work
experience that will prepare them for the future (see www.militaryhomefront.dod.mil).
31
The Warrior Athlete Reconditioning program provides recreational activities and
competitive athletic opportunities to recovering servicemembers to improve their physical
and mental quality of life throughout the continuum of recovery and transition. The
program is designed to enhance recovery by engaging recovering servicemembers in
physical and cognitive activities outside of traditional therapy settings.
32
Servicemembers do not have to be enrolled in or attached to a wounded warrior
program to participate in the VA Liaison for Healthcare Program or the Warrior Athlete
Reconditioning Program.
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congressional committees, the Recovering Warrior Task Force noted that
as a result of differences in eligibility criteria among the military services,
certain subpopulations of recovering servicemembers may be at a
disadvantage. 33 In response to this report, DOD stated that although there
are no DOD-wide criteria for entry into wounded warrior programs, the
individual military services already have policies in place as a result of the
flexibility given to them by DOD.
Delays in DOD’s and VA’s
Integrated Disability
Evaluation System Persist,
Limiting Recovering
Servicemembers’ Ability to
Plan for Their Future
Although IDES provides improved timeliness over the separate DOD and
VA disability evaluation systems, processing times have continued to
increase since its implementation in November 2007, resulting in
frustration and uncertainty for servicemembers going through the
process. In a May 2012 hearing, 34 we testified that the average number of
days for servicemembers to complete the IDES process and receive VA
benefits increased from 283 in fiscal year 2008 to 394 in fiscal year 2011
for active duty cases (compared to the goal of 295 days) and from 297 to
420 for reserve cases, respectively (compared to the goal of 305 days). 35
While there are many reasons for increases in processing times, 36
recovering servicemembers and wounded warrior program officials told
us that extended timelines in the IDES process and the lack of a firm
completion date limits recovering servicemembers’ ability to plan for their
future. Several recovering servicemembers said that not being given a
timeframe for completion of the IDES process is frustrating, particularly
when their own providers are unable to obtain additional information on
33
Recovering Warrior Task Force, Department of Defense Recovering Warrior Task Force
2010-2011 Annual Report.
34
GAO, Military Disability System: Preliminary Observations on Efforts to Improve
Performance, GAO-12-718T (Washington, D.C.: May 23, 2012). For additional
information about IDES, see reports listed on the related products page.
35
The fiscal year 2008 and 2011 averages include only those servicemembers who
completed IDES and received VA benefits. The averages do not include other outcomes,
such as servicemembers who were found fit and returned to duty. Not all reservists
complete the VA benefit phase and thus DOD does not apply the 30-day goal for this
phase to reservists. For those reservists who do go through the VA benefits phase, this
time is reflected in the overall time in IDES.
36
As we have previously testified, other reasons that could impact the increase in IDES
processing times include large case loads and insufficient staff to complete a stage of
IDES in a timely manner.
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the status of their case. For example, a servicemember told us that after
going through the IDES process, receiving a rating, and filing an appeal
over a year ago, he still did not know the status of his case, negatively
affecting his ability to plan for his future. Similarly, a wounded warrior
program official also told us that her program has had several
servicemembers lose job opportunities because they applied for positions
thinking that they would be through the IDES process by a certain date,
but when that date was pushed back, the employers rescinded their
offers.
Wounded warrior program officials from some of the sites we visited told
us that extended waiting periods resulting from the disability process also
may lead to some recovering servicemembers engaging in negative
behavior, including drug use. Wounded warrior program officials told us
that after waiting for so long in the wounded warrior barracks due to the
lengthy disability process, servicemembers can get depressed, resist or
just stop going to medical appointments, and stop working on their
recovery. Similarly, the DOD Inspector General has reported that lengthy
IDES processing times has contributed to a negative and even
counterproductive environment, which was not conducive to
servicemembers’ recovery and transition. 37 To prevent these problems,
we found that two wounded warrior programs require recovering
servicemembers to participate in programs such as the Warrior Athlete
Reconditioning Program and Operation Warfighter. A recovering
servicemember told us that soon after being assigned to the wounded
warrior program, he was referred to the Warrior Athlete Reconditioning
Program, which gave him something to do other than “sitting around.”
Another recovering servicemember told us that the Warrior Athlete
Reconditioning Program is an effective motivator for recovery.
Conversely, the servicemembers could take actions that may impact their
own processing times in IDES and, therefore, their length of stay in a
wounded warrior program. We found that some servicemembers may
appeal their disability decisions to prolong their own recovery and
transition out of the military. According to wounded warrior program
37
Department of Defense Office of the Inspector General, Special Plans and Operations,
Assessment of DOD Wounded Warrior Matters-Camp Lejeune (March 2012) and
Department of Defense Office of the Inspector General, Special Plans and Operations,
Assessment of DOD Wounded Warrior Matters-Wounded Warrior Battalion-West
Headquarters and Southern California Units (August 2012).
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officials from some of the sites we visited, some servicemembers resist
their transfer out of the wounded warrior program and the military
because they want to continue to take advantage of the opportunities and
services available to them, including the financial security of a regular
paycheck. For example, a wounded warrior program official and a VA
official told us that some servicemembers will purposefully miss
appointments to delay the IDES process because they feel that they are
not ready to leave the program.
DOD and VA Have Yet to
Develop Sufficient
Capability to
Electronically Share
Health Records,
Potentially Delaying
Servicemembers’ Receipt
of Coordinated Care and
Benefits
The departments have not yet developed sufficient capability to
electronically share servicemembers’ and veterans’ complete health
records, which can delay the receipt of care and benefits for recovering
servicemembers and veterans. As we have previously reported, for over a
decade DOD and VA have undertaken several efforts to improve the
ability of their information technology systems to electronically share
health records. 38 For example, the Federal Health Information Exchange,
which was started in 2001 and completed in 2004, allows DOD to
electronically transfer servicemembers’ health information to VA when
they leave active duty. In addition, the departments’ Bidirectional Health
Information Exchange was established in 2004 to allow clinicians in both
departments to view limited health information on patients who receive
care from both departments. More recently, the departments have
undertaken two new joint initiatives, the Virtual Lifetime Electronic Record
and an integrated electronic health records system, in an effort to
increase electronic health record interoperability and modernize their
systems.
We found that although DOD and VA care providers were expected to
have access to some electronic health record information across the
departments, the DOD and VA care providers that we spoke to still did
not have the ability to electronically share complete health records for
recovering servicemembers who were transferring between DOD’s and
VA’s health care systems, and therefore they had to use other methods.
38
See, for example, GAO, Electronic Health Records: DOD and VA Efforts to Achieve Full
Interoperability Are Ongoing; Program Office Management Needs Improvement,
GAO-09-775 (Washington, D.C.: July 28, 2009); Electronic Health Records: DOD and VA
Interoperability Efforts Are Ongoing; Program Office Needs to Implement Recommended
Improvements, GAO-10-332 (Washington, D.C.: Jan. 28, 2010) and Electronic Health
Records: DOD and VA Should Remove Barriers and Improve Efforts to Meet Their
Common System Needs, GAO-11-265 (Washington, D.C.: Feb. 2, 2011).
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For example, wounded warrior program and VA officials told us that they
had to resort to copying and faxing recovering servicemembers’ health
records to VAMC staff in preparation for a servicemember’s transition
from DOD’s to VA’s health care system because there was not an
automatic, electronic way to transfer them. In addition to copying and
faxing health records, according to VA officials we spoke with, DOD and
VA staff may hold a video-teleconference between the transferring MTF
and receiving VA health care facilities to exchange information.
In addition, wounded warrior program and VA officials who help
servicemembers transition from DOD to VA told us that they only share
with VA facilities the health records necessary for the treatment of a
recovering servicemember’s current condition. As a result,
servicemembers’ and veterans’ complete health records are not always
shared between departments when transferring facilities, and ultimately,
the responsibility to collect and provide a complete health record to the
VA facility can fall on the recovering servicemember and veteran. 39 A VA
official told us that this process can be complicated because DOD
separately maintains servicemembers’ inpatient, outpatient, and
behavioral health records and does not have a single database that can
identify all of the medical facilities where a servicemember received
treatment. Further, according to VA and DOD officials, delaying the
collection and assembly of a servicemember’s complete medical history
until the start of the disability process could result in servicemembers
having to be reexamined when they are demobilized, needing to establish
that their injuries were connected to their time in the military, thus possibly
delaying a servicemember’s or veteran’s receipt of VA benefits.
Both departments have needed to create programs and provide staff to
assist recovering servicemembers during their transition from a DOD MTF
to a VAMC. For example, VA Liaisons and DOD nurse case managers
help recovering servicemembers transition from DOD to VA by
assembling their health records and sharing them with the VAMC where
the servicemember will be receiving treatment. According to DOD and VA
39
DOD policy requires that, upon retirement, discharge, or end of active obligated service,
records be transferred to the VA Records Management Center if the servicemember is not
applying for VA benefits or the appropriate VA Regional Office if the servicemember has
applied or plans to apply for VA benefits. Department of Defense, Service Treatment
Record (STR) and Non-Service Treatment Record (NSTR) Life Cycle Management, DOD
Instruction 6040.45, Enclosure 3, (Oct. 28, 2010). The transfer of records from DOD to a
VA medical facility is achieved under different procedures.
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GAO-13-5 Recovering Servicemembers and Veterans
staff that assist servicemembers in their transition from one system to
another, DOD nurse case managers at installations that do not have VA
Liaisons do not always have the same knowledge of VA services and
benefits, and may not be informed of the appropriate referral methods or
contacts used by VA Liaisons to provide a servicemember with a
seamless transition to a VAMC. A DOD official told us that at locations
where the VA Liaison program is not available, the transition process for
recovering servicemembers from DOD to VA is more difficult. This official
understood how to properly transfer servicemembers’ records from the
DOD facility to the receiving VA facility only because of past VA
experience.
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GAO-13-5 Recovering Servicemembers and Veterans
DOD and VA Have
Not Fully Resolved
Long-standing
Problems Due to
Deficiencies in
Leadership and
Oversight, Resources,
and Collaboration
Lack of Leadership and
Oversight Has Limited
DOD’s and VA’s Ability to
Effectively Manage
Programs for Recovering
Servicemembers and
Veterans
The lack of leadership and program oversight has limited DOD’s and VA’s
ability to effectively manage programs created to serve recovering
servicemembers and veterans. Two bodies established to oversee these
programs, the Senior Oversight Committee and the Office of Wounded
Warrior Care and Transition Policy (WWCTP), 40 lacked consistent
leadership attention and oversight capabilities. In addition, DOD does not
have a central office that oversees or collects common data on the
military services’ wounded warrior programs.
Strength of Senior Oversight
Committee Leadership Waned
Before the Senior Oversight Committee was consolidated into the Joint
Executive Council 41 in early 2012, it had already lost many of the
characteristics that had made it a strong decision making and oversight
body for the programs and initiatives created to assist recovering
servicemembers and veterans. What had originally made it strong were
40
In 2008, DOD established the Office of Transition Policy and Care Coordination which
was renamed the Office of Wounded Warrior Care and Transition Policy (WWCTP).
Reporting to the Under Secretary of Defense for Personnel and Readiness, up until June
2012, WWCTP served as a single, centralized office for developing policy, coordinating
interagency collaboration, and conducting outreach to address the broad set of issues
confronted by wounded, ill and injured service members and their families. WWCTP also
provided program oversight for the integrated disability evaluation system process and
care coordination.
41
The Joint Executive Council was established by law in November 2003 to provide senior
leadership for collaboration and resource sharing between DOD and VA. Through a joint
strategic planning process, the Joint Executive Council recommends to the Secretaries
the strategic direction for the joint coordination and sharing efforts between the two
departments and oversees the implementation of those efforts.
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GAO-13-5 Recovering Servicemembers and Veterans
•
high-level leadership participation without substitution of lower-ranking
officials,
•
rapid policy development and quick decision making, and
•
rigorous monitoring to hold the military services and the two
departments accountable for needed actions.
Sustaining the Senior Oversight Committee’s original momentum over
time became difficult, and its waning influence and effectiveness became
evident in a number of ways:
•
Starting in December 2008, the Senior Oversight Committee
experienced leadership changes, including the departure of its
cochairs, the Deputy Secretaries, 42 as well as turnover in some of its
key staff. According to a former Senior Oversight Committee
executive, the personal commitment and strong relationship between
the Deputy Secretaries who initially cochaired the Senior Oversight
Committee served as a unifying and confidence building force that
was not replicated by subsequent leadership, while leadership
turnover in the DOD offices supporting the Senior Oversight
Committee negatively impacted its ability to function effectively.
•
As we have previously reported, the Senior Oversight Committee also
began to encounter challenges when DOD “disrupted the unity of
command” by changing the organizational structure of the committee
and realigning and incorporating the committee’s staff and
responsibilities into existing or newly created DOD and VA offices,
such as WWCTP. 43 Officials formerly involved with the committee told
us that the new staffing arrangement did not adequately support the
committee’s efforts, and VA did not provide full-time staff members to
support the committee, as it had in the past. Later in October 2008,
VA established the Office of VA/DOD Collaboration Services, and VA
supported Senior Oversight Committee efforts, along with broader
collaboration efforts, through this separate office.
42
With the change of presidential administration in January 2009, the Deputy Secretary of
Defense and Deputy Secretary of Veterans Affairs were replaced.
43
GAO-09-728.
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GAO-13-5 Recovering Servicemembers and Veterans
•
The committee began meeting less frequently. For example, in
contrast to weekly meetings held during its initial year of operation, in
fiscal year 2011, the committee met less than 11 hours in total.
•
Top DOD leadership no longer consistently attended Senior Oversight
Committee meetings. According to a former Senior Oversight
Committee official, the second Deputy Secretary of Defense to
cochair the committee sent the Deputy Undersecretary of Defense for
Personnel and Readiness to represent DOD in his place.
•
The Senior Oversight Committee no longer made relatively quick
decisions. According to former Senior Oversight Committee executive
and support staff, frequent substitutions by lower-ranking officials at
Senior Oversight Committee meetings no longer allowed for quick
decision making and transformed Senior Oversight Committee
meetings into informational briefings.
•
The Senior Oversight Committee no longer tracked or monitored
progress of its policy initiatives or assigned tasks. According to a
former LOA cochair and a cognizant support staff member, by 2011
the Senior Oversight Committee was no longer routinely using a
tracking mechanism to hold the departments accountable for
completing appointed tasks. Later that year, the Recovering Warrior
Task Force reported that the Senior Oversight Committee no longer
had a formal mechanism for assessing the status of the committee’s
initiatives and goals, leaving no way to determine whether initiatives
or goals had been partially or fully implemented or met.
In its September 2011 report, the Recovering Warrior Task Force
recommended combining the Senior Oversight Committee and Joint
Executive Council to improve effectiveness and reduce redundancies as
both entities had similar membership and operating structures. In January
2012, the Joint Executive Council cochairs agreed to consolidate the two
groups. The Senior Oversight Committee’s working groups for care
coordination and the integrated disability evaluation system were
realigned within the Joint Executive Council, and a Wounded, Ill, and
Injured Council was established under the Joint Executive Council to
oversee emerging issues for recovering servicemembers and veterans.
Whether the Joint Executive Council can effectively address the issues
once managed by the Senior Oversight Committee has yet to be seen.
Several DOD and VA officials expressed concern to us about the ability of
the Joint Executive Council to focus on rapid, short-term policy decision
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GAO-13-5 Recovering Servicemembers and Veterans
making rather than the longer-term strategic planning role that it has
traditionally played. For example, according to a DOD official, historically,
the Joint Executive Council has not been able to drive policy decision
making, and therefore, issues that should have been decided by the Joint
Executive Council were taken directly to the Secretaries for resolution,
raising doubts about the ability of the Joint Executive Council to function
effectively. A former Senior Oversight Committee executive noted that the
Joint Executive Council cochairs are not of equivalent rank, another
challenge that may serve as a barrier to the council’s ability to make
decisions and drive policy changes. Specifically, the VA cochair is the
Deputy Secretary, who has control over all relevant offices within VA,
while the DOD cochair is the Deputy Undersecretary of Defense for
Personnel and Readiness, whose responsibilities include establishing
health and benefit policies affecting recovering servicemembers and
directing the military services to comply with such policies but lacks
authority in enforcing the military services’ implementation of these
policies. The Recovering Warrior Task Force also cited concerns about
the rank of the DOD cochair of the Joint Executive Council, stating that a
higher level of leadership is needed to sustain departmental attention on
key initiatives such as IDES and electronic health records. 44 Furthermore,
as of August 2012, DOD officials told us that the Joint Executive Council
is operating under the original procedures that were in place prior to the
entities merging. As a result, it is unclear at this time how the Joint
Executive Council will provide oversight and accountability for issues
once addressed by the Senior Oversight Committee.
WWCTP Lacks Authority and
Leadership to Provide
Oversight for Care
Coordination
In 2008, WWCTP became responsible for overseeing the RCP among
other programs that provide assistance to recovering servicemembers.
However, WWCTP’s ability to oversee the RCP, including its ability to
monitor program performance and ensure compliance with DOD policy, is
limited by its lack of operational authority, such as budget and tasking
authority, over the military services that implement the program.
According to WWCTP officials, this lack of operational authority
challenges WWCTP’s ability to direct the military services on their
implementation of the program. For example, although WWCTP has been
responsible for RCP oversight since 2008, the office was not able to
collect basic program data, such as monthly enrollment numbers, on a
44
Department of Defense Task Force on the Care, Management, and Transition of
Recovering Wounded, Ill, and Injured Members of the Armed Forces, Department of
Defense Recovering Warrior Task Force 2011-2012 Annual Report (August 2012).
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GAO-13-5 Recovering Servicemembers and Veterans
consistent basis until October 2011. According to a WWCTP official,
although WWCTP requested monthly data submissions from the military
services, the information was provided on an ad hoc basis; sometimes
the services would submit it, and other times they would not. Datacollection efforts still remain a challenge for WWCTP. For example, the
Army’s Wounded Warrior Program, which serves as the Army’s care
coordination program, only agrees to share partial data with WWCTP,
arguing that the Army is only obligated to share data on servicemembers
served by WWCTP-contracted personnel.
Getting the military services to implement consistent care coordination
policies also poses a challenge for WWCTP. WWCTP officials said that
while WWCTP can develop policy to guide the military services, the
military services may interpret that policy and implement their programs
differently. Consequently, some DOD officials assert that the military
services have not consistently implemented the RCP in accordance with
DOD policy—an observation that is shared by the Recovering Warrior
Task Force. 45 DOD policy requires that care coordination should be
provided to those who are “seriously” and “severely” wounded, ill, and
injured, but the Army only provides care coordination to recovering
servicemembers who are “severely” wounded, ill, and injured. 46 As a
result, some servicemembers who could benefit from having someone
coordinate their care and benefits as they navigate the recovery care
continuum do not have access to those services.
Some WWCTP officials with whom we spoke expressed the view that the
military services have been inconsistent in their cooperation with
WWCTP, with cooperation being better on issues that represent priorities
of top leadership. Specifically, WWCTP officials told us that top DOD
leadership has not been pressured to resolve lingering care coordination
issues as much as other more visible issues, such as IDES and electronic
medical record interoperability problems confronting the departments.
Consequently, WWCTP officials said that the military services cooperate
with WWCTP’s efforts to oversee IDES and to monitor whether the
military services achieve their goals for timely completion of the IDES
45
Recovering Warrior Task Force, Department of Defense Recovering Warrior Task Force
2011-2012 Annual Report.
46
Department of Defense, Recovery Coordination Program, DOD Instruction 1300.24,
(Dec. 1, 2009).
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GAO-13-5 Recovering Servicemembers and Veterans
process. Although these goals have not consistently been achieved, 47 the
officials told us that military service cooperation has not been an
impediment to overseeing IDES as it has been for overseeing care
coordination. Conversely, the military services have not been as inclined
to cooperate with WWCTP on its oversight of the RCP relative to these
other issues.
In addition to limited operational authority over the military services,
turnover in leadership and other staffing changes have also limited
WWCTP’s ability to provide consistent direction and oversight for the
RCP, according to WWCTP officials. Specifically:
•
Three different DOD officials have led WWCTP since its inception in
2008. According to WWCTP staff, each of these officials had different
visions and priorities for the office, which led to disruptions in RCP
oversight. For example, a major oversight initiative—to collect
satisfaction survey data across the RCP—was abandoned when a
new official was appointed. In addition, the RCP has been led by three
different directors, with the most recent director leaving in June 2012.
•
In September through December 2011, WWCTP’s contracted staffing
was temporarily reduced by 70 percent when a contract expired and
was not immediately renewed, according to DOD. Staff reductions
primarily impacted WWCTP’s ability to oversee the RCP, since many
RCP support staff members were lost. For example, according to a
WWCTP official, the office was no longer able to make monitoring
visits to the RCP program sites. However, in July 2012 a contract was
awarded that allowed WWCTP to engage additional staff to support
the RCP, according to a WWCTP official.
•
In June 2012, DOD changed the name of the WWCTP office to the
Office of Warrior Care Policy and moved it under the Assistant
Secretary of Defense for Health Affairs. According to a DOD official,
the change was made as part of a realignment of DOD’s
organizational structure in response to statutory requirements. 48 An
47
See GAO, Military and Veterans Disability System: Pilot Has Achieved Some Goals, but
Further Planning and Monitoring Needed, GAO-11-69 (Washington, D.C.: Dec . 6, 2010);
Military and Veterans Disability System: Worldwide Deployment of Integrated System
Warrants Careful Monitoring, GAO-11-633T (Washington, D.C.: May 4, 2011); and
GAO-12-718T.
48
See Pub. L. No. 111-84, § 906, 123 Stat. 2190, 2425 (2009).
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GAO-13-5 Recovering Servicemembers and Veterans
official in Health Affairs said that the move will be beneficial because it
will provide greater access to resources, including human resources
and information technology, among others. However, it is too early to
determine the full effect of this change.
Wounded Warrior Programs
Lack Central Oversight
There is currently no central office or authority that oversees or collects
common data on the military services’ wounded warrior programs,
preventing DOD from both assessing how well the programs are working
across the department and leveraging the strengths of each program by
sharing proven best practices across the military services.
Each of the military service Secretaries created their own wounded
warrior programs to meet their military service’s unique needs. Because
each service developed its own policy to govern its wounded warrior
programs and no central, unified DOD policy exists to govern these
programs, no central DOD office—such as WWCTP—may direct how
these programs operate. This lack of central oversight over the wounded
warrior programs has been one of the main reasons for the large
discrepancies between these programs. The 2011 Recovering Warrior
Task Force report recommended that the Secretary of Defense enforce
the existing policy guidance regarding the Army’s and Marines’ wounded
warrior transition units’ entrance criteria. However, in its response to this
recommendation, DOD supported the military service Secretaries’
discretion in establishing their own policies in this regard, saying that
there is no central DOD policy on the establishment of transition units and
entrance criteria, and that the policies were established by the
Secretaries for their specific populations.
While no common data are collected on the performance of wounded
warrior programs across the military services, each individual program
has initiated internal efforts to collect and analyze performance data. The
type and quality of data vary by program, however. For example, the
largest of the wounded warrior programs, the Army Warrior Care and
Transition Program, has collected wounded warrior program performance
survey data on a continuous basis since March 2007 and has developed
outcome measures to determine the impact of its services. However,
smaller programs, such as the Air Force Wounded Warrior Program and
the United States Special Operations Command’s Care Coalition have
measured baseline program satisfaction levels, but they do not have
additional years of survey data to monitor any changes over time. (See
table 3 for information about the types of performance data collected by
each of the wounded warrior programs.)
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GAO-13-5 Recovering Servicemembers and Veterans
Table 3: Military Services’ Wounded Warrior Program Efforts to Measure Program Performance
Satisfaction surveys:
Measures customer
satisfaction with program
Performance metrics:
Measures whether
program meets target
output goals
Outcome measures:
Measures whether program
achieves desired impact
Army Warrior Care and Transition
Program



Army Wounded Warrior Program





Military services’ wounded
warrior program
Army
Navy/Coast Guard
Navy Safe Harbor Program
Air Force
a
Air Force Wounded Warrior Program

Air Force Recovery Care Program

a





Marine Corps
Marine Corps Wounded Warrior
Regiment

United States Special
Operations Command
United States Special Operations
Command’s Care Coalition
b
Source: GAO analysis of interviews with military services’ wounded warrior program officials and program documentation.
a
Although the Air Force Wounded Warrior and Recovery Care Programs’ initial satisfaction survey
was completed in October 2011, the survey results have not been released as of August 9, 2012.
b
The United States Special Operations Command’s Care Coalition has performance metrics for its
Recovery Program.
Some DOD officials with whom we spoke questioned why common
measures have not been developed. For example, a DOD official in
charge of wounded warrior care at an MTF suggested developing a
measurement tool to determine what aspects of the programs help
recovering servicemembers. Another DOD official involved with wounded
warrior program performance measurement commented that it is common
practice for DOD to share performance measurement practices and
standard metrics across the military services.
In September 2011, citing wide disparity across the military services in
their implementation of wounded warrior programs and policies, the
Recovering Warrior Task Force made four recommendations for creating
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common standards to ensure parity in the programs and services
provided to recovering servicemembers across DOD. 49 For example, the
first recommendation called for a common nomenclature, or consistent
definitions to be used in DOD policy to identify recovering
servicemembers who may require and be eligible for assistance. The task
force concluded that common definitions are needed to promote
consistent levels of care among the military services and would better
enable DOD to compare across programs and identify best practices. In
its response to the task force, DOD acknowledged that some of these
recommendations were valid and that DOD should take actions to
address them. However, at the time of the Recovering Warrior Task
Force’s 2012 report, these recommendations had not been implemented,
and the task force is continuing to follow DOD’s efforts to implement
them. 50 Moreover, even if DOD decided to take some actions in this
regard, it is unclear who would have responsibility for addressing them,
since there is no central oversight office or authority for these programs.
Insufficient Staffing and
Budget Control Have
Contributed to DOD’s and
VA’s Inability to Resolve
Delays with Disability
Determinations and
Electronically Share
Health Records
In addition to problems with leadership and oversight of care coordination
and case management programs, DOD and VA have a longstanding track
record of insufficient staffing to address delays in disability determinations
and insufficient staffing and control over the budget to oversee the
development of systems with improved capabilities for electronically
sharing health records. 51
49
Recovering Warrior Task Force, Department of Defense Recovering Warrior Task Force
2010-2011 Annual Report.
50
Recovering Warrior Task Force, Department of Defense Recovering Warrior Task Force
2011-2012 Annual Report.
51
See GAO-11-69; GAO-11-633T; GAO-12-718T; Electronic Health Records: DOD and
VA Have Increased Their Sharing of Health Information, but More Work Remains,
GAO-08-954 (Washington, D.C.: July 28, 2008); Electronic Health Records: DOD’s and
VA’s Sharing of Information Could Benefit from Improved Management, GAO-09-268
(Washington, D.C.: Jan. 28, 2009); Information Technology: Challenges Remain for VA’s
Sharing of Electronic Health Records with DOD, GAO-09-427T (Washington, D.C.:
Mar. 12, 2009); GAO-09-775; and GAO-10-332.
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Insufficient Staffing
Contributed to Delays in
Disability Determinations
Insufficient staffing across both departments has affected DOD’s and
VA’s ability to reduce disability determination delays and meet their IDES
timeliness goals. We raised concerns about staffing in 2010, when we
reported that DOD and VA did not sufficiently staff many key positions in
the IDES process, including DOD board liaisons, who counsel
servicemembers and ensure that documentation submitted for
consideration is complete and accurate, and medical evaluation board
physicians, who review medical and service records to identify conditions
that limit a servicemember’s ability to serve in the military. 52 In 2012, we
continued to report evidence of staffing shortages, including high
caseloads for DOD board liaisons and VA case managers as well as
insufficient numbers of physicians to write narrative summaries needed to
complete the medical evaluation board stage of the IDES process in a
timely manner. 53 Some recovering servicemembers told us they do not
receive sufficient support from their DOD board liaisons, and that there
are not enough liaisons to efficiently meet the needs of all the recovering
servicemembers going through the IDES process.
Delays in the disability determination process are expected to continue.
VA anticipates a much larger caseload of all disability and other benefit
claims in the near future, not just those claims associated with IDES
cases. Specifically, a high-level VA official told us that new laws, such as
the Veterans Opportunity to Work Act, 54 will encourage all transitioning
servicemembers—not just those going through the IDES process—to
claim VA benefits. This official also told us that DOD and VA have a much
larger problem to address as a surge of 300,000 servicemembers begin
to transition into the VA system as troops return home from Iraq and
Afghanistan. Without adequate planning and adequate resources, these
servicemembers may experience much longer processing times in the
disability benefits systems.
DOD and VA are working to address staffing challenges in some of the
IDES processes that are most delayed. We have previously reported that
the Army, for example, is in the midst of a major hiring initiative to
increase staffing dedicated to its medical evaluation boards, which will
52
GAO-11-69.
53
GAO-12-718T.
54
Veterans Opportunity to Work (VOW) to Hire Heroes Act, Pub. L. No. 112-56, tit. II, 125
Stat. 712 (2011).
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include additional DOD board liaisons and medical evaluation board
physician positions. 55 Additionally, VA officials said that the agency has
added staffing to its IDES rating sites to handle the demand for
preliminary disability ratings, rating reconsiderations, and final benefit
decisions, which has increased the number of preliminary VA ratings
completed and slightly improved processing times. But it is too early to tell
the extent to which VA’s efforts will continue to improve processing times.
Lack of Staffing and Budget
Control Limited Progress on
Electronic Health Records
Sharing
The Interagency Program Office was established by law 56 to serve as a
single point of accountability for joint DOD and VA efforts to implement
fully interoperable electronic health record systems or capabilities, but this
office was not given sufficient staffing or budget control by DOD and VA
to effectively facilitate the departments’ efforts. According to an
Interagency Program Office official, the office was never fully staffed and
was challenged by a high degree of turnover in staffing and leadership
that served in a temporary or acting capacity.
The Interagency Program Office’s initial charter limited its ability to
exercise authority over DOD and VA. Specifically, the charter stated that
control of the budget, contracts, and technical development remained
wholly within the two departments’ program offices. The charter conveyed
no authority in these areas to the Interagency Program Office. As a
former Interagency Program Office official testified in July 2011, the office
lacked control of budgeting and contracting necessary to achieve its
intended purpose, and without this, it could not sufficiently oversee the
departments’ efforts and compliance with the requirements in NDAA
2008. 57 As a result, each department continued to pursue separate
strategies, rather than a unified interoperable approach, according to this
former official.
55
GAO, Military System: Improved Monitoring Needed to Better Track and Manage
Performance. GAO-12-676 (Washington, D.C.: Aug. 28, 2012).
56
See Pub. L. No. 110-181, § 1635, 122 Stat. 3, 460-63 (2008).
57
Legislative Hearing on H.R. 2383, H.R. 2388, H.R. 2243 and H.R. 2470, Before the
Subcommittee on Oversight and Investigations of the Committee on Veterans Affairs,
112th Cong. (July 20, 2011) (statement of Debra M. Filippi, former Director, U.S.
Department of Defense/U.S. Department of Veterans Affairs Interagency Program Office).
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The Interagency Program Office was rechartered in October 2011 and
provided an expanded staff and new authorities under the charter,
including control over the budget. According to Interagency Program
Office officials, when hiring under the new charter is completed, the office
will have a staff of 236 personnel, more than seven times the number of
staff originally allotted to the office by DOD and VA. 58 In addition, the
charter provides the Interagency Program Office with the authority to
lead, oversee, and manage budget and contracting for electronic health
record sharing efforts. According to Interagency Program Office officials,
budget control is the essential component for overseeing progress and
ensuring accountability for the departments’ efforts.
With the enhanced charter, as well as plans for an expanded staff to
oversee the implementation of a single joint electronic health record
system, the Interagency Program Office will have more resources to draw
upon and support department interoperability initiatives. However, it is still
too early to determine whether this investment of resources will be
sufficient to meet the office’s goals for 2017. 59 For example, despite the
provision of additional resources, Interagency Program Office officials told
us that as of July 2012, the office is staffed at approximately 48 percent
and that hiring additional staff in time to meet appointed implementation
deadlines remains one of its biggest challenges.
Despite Repeated
Attempts, DOD and VA
Have Failed to Effectively
Collaborate to Align Their
Care Coordination
Programs; New Efforts Are
Under Way
Since the inception of the RCP in 2008, the FRCP and RCP care
coordination programs have conflicted with one another and with other
case management programs that provide services to recovering
servicemembers and veterans. Conflicting issues have arisen as to what
populations they serve, the specific services each would provide, and
when each program would get involved in the servicemembers’ recovery
process. Aligning and integrating these programs with one another—
especially the FRCP with the RCP—has proven to be a major challenge
for DOD and VA. While the departments are developing an interagency
strategy for minimizing duplication between DOD’s and VA’s care
coordination and case management programs, the success of this effort
58
As we reported in 2008, the Interagency Program Office was in the process of recruiting
about 30 permanent staff members (see GAO-08-954).
59
According to DOD and VA officials, the departments have identified 54 joint capabilities
that will be implemented by the end of fiscal year 2017.
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GAO-13-5 Recovering Servicemembers and Veterans
will depend upon achieving cooperation between the departments—which
has been elusive for many years—as well as with the military services.
With the creation of the RCP, the FRCP was no longer the single point of
contact with respect to servicemembers’ care coordination, and early on,
there were concerns and some confusion about how the FRCP and the
RCP would align without creating overlapping and duplicative services.
Shortly after the RCP was established, DOD sent a report to
congressional committees outlining a medical category assignment
process that was based on the severity of each servicemember’s medical
condition, along with input from the servicemember and his or her unit
commander, to determine whether servicemembers would be directed to
either the FRCP or to the RCP for care coordination services. In concept,
the medical category assignment process would have resulted in
wounded, ill, and injured servicemembers being assigned to one of three
categories: “mild,” “serious,” or “severe.” Under this approach, the FRCP
would provide care coordination services for “severely” wounded, ill, and
injured servicemembers and the RCP would serve those who were
“seriously” wounded, ill, and injured. (See app. II for additional information
on the intended medical category assignment process for DOD and VA
care coordination programs.)
Despite DOD’s attempt to define the populations served by the FRCP and
the RCP, neither the military services’ wounded warrior programs, which
implement the RCP, nor VA, which administers the FRCP, implemented
DOD’s assignment process. Instead, these programs expanded their
enrollment to include both “seriously” and “severely” recovering
servicemembers and veterans, which resulted in both programs serving
the same populations, thereby setting up the likelihood of overlap and
duplication of services. As we have previously reported, this duplication
issue is compounded by the numerous other programs that also provide
services to recovering servicemembers and veterans and have
overlapping roles as well. It is not uncommon for recovering
servicemembers to be enrolled in more than one case management or
care coordination program and end up with multiple care coordinators and
case managers—each of whom develop different care plans for the same
servicemember. The care plans may even conflict with one another,
which could conceivably adversely affect the servicemember’s recovery
process. In fact, in the course of previous work, we found instances
where inadequate information exchange and poor coordination between
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GAO-13-5 Recovering Servicemembers and Veterans
these programs resulted not only in duplication of effort and overlap of
services, but also confusion and frustration for servicemembers and their
families. 60 In addition, DOD and VA officials acknowledge that the
multiplicity of care coordination and case management programs causes
confusion even among members of care coordination teams. In October
2011, we recommended that the Secretaries of Defense and Veterans
Affairs direct the Senior Oversight Committee to expeditiously develop
and implement a plan to strengthen functional integration across all DOD
and VA care coordination and case management programs to reduce
redundancy and overlap.
Although DOD and VA have not yet aligned care coordination policy for
the FRCP and RCP, we have found indications that care coordinators and
case managers at some locations have been cooperating to some degree
and trying to work more closely with one another. In the course of our
visits to 11 DOD and VA facilities during this review, we found that care
coordinators and case managers in many locations had attempted—with
some success—to clarify their roles and to limit the degree of overlap and
duplication in the services they provide to recovering servicemembers
and veterans. However, such local attempts to improve the degree of
cooperation and coordination among the programs are not systemic and
depend on individual personalities and circumstances. They may not be
sustainable without agreement by DOD and VA and the alignment of
policy governing case management and care coordination programs.
Another critical issue on which DOD and VA have disagreed pertains to
the stage in a servicemember’s recovery when the FRCP should get
involved in the coordination of services. Because the FRCP depends on
referrals from other programs as a basis for becoming involved with
recovering servicemembers, this can be a significant issue. Currently,
neither DOD nor VA policy clearly defines when referrals are to be made;
consequently, most wounded warrior programs delay referrals to the
FRCP until it becomes clear that the servicemember will be separated
from the military. Senior DOD officials stated that wounded warrior
program officials justify this practice on the basis that referring a recently
wounded servicemember to the FRCP—a VA-operated program—sends
a negative message to a recovering servicemember that his or her
military career has ended, even though the FRCP was designed as a joint
60
GAO-12-129T.
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program. Additionally, the belief among the military that they should “take
care of their own,” contributes to the reluctance to involve the FRCP. On
their part, VA maintains that its point of engagement should be in the
early stage of medical treatment to build rapport and trust and to begin
coordinating the services needed by severely wounded servicemembers.
Despite multiple efforts over the last several years to align their care
coordination and case management programs, DOD and VA have failed
to implement lasting measures to resolve underlying problems concerning
the aligning of roles and responsibilities of the FRCP, RCP, and case
management programs. Previous attempts include the following:
•
December 2010. The Senior Oversight Committee directed its case
management work group to perform a feasibility study of
recommendations on the governance, roles, and mission of DOD and
VA care coordination. However, no action was taken by the committee
and care coordination was subsequently removed from the Senior
Oversight Committee’s agenda as other issues were given higher
priority.
•
March 2011. WWCTP sponsored a joint summit that included officials
from VA and the military services to review DOD and VA care
coordination issues. Although this collaboration resulted in the
development of five recommendations related to care coordination, no
agreement was reached by the departments to jointly implement
them. A DOD participant told us that VA did not agree with the
recommendations, and a VA official involved in the summit concurred,
alleging that the recommendations appeared to suggest eliminating
overlap and duplication between the FRCP and RCP by ending the
FRCP.
•
May 2011. Concerned with overlap and duplication between the DOD
and VA care coordination programs, the House Committee on
Veterans Affairs, Subcommittee on Health directed the Deputy
Secretaries of DOD and VA to provide an analysis of how the FRCP
and RCP could be integrated under a “single umbrella” by June 20,
2011. In the absence of such a response, the subcommittee
scheduled a congressional hearing and requested that options for
addressing this issue be presented. Following the notification of the
hearing, the departments developed a joint letter and submitted it to
the subcommittee in September 2011. This letter, however, did not
identify or outline options for aligning the FRCP and the RCP. In a
hearing held by the subcommittee in early October 2011, neither VA
nor DOD outlined definitive plans to address this issue.
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•
September 2011. The Recovering Warrior Task Force issued the first
of four annual reports that included 21 recommendations, including a
recommendation that the roles of care coordinators be clarified. In
DOD’s official response to congressional committees, the Under
Secretary of Defense stated that the department would implement the
Recovering Warrior Task Force’s recommendations. However, a
Recovering Warrior Task Force member stated that the Recovering
Warrior Task Force concluded that in most cases DOD has not made
significant changes to its programs to achieve the outcomes intended
by the recommendations. In August 2012, the Recovering Warrior
Task Force reported that DOD has fully implemented only 2 of the 21
recommendations. 61 However, a DOD official whose office is
responsible for coordinating DOD’s responses to the Recovering
Warrior Task Force’s recommendations stated that DOD is in the
process of addressing several more of the 2011 Recovering Warrior
Task Force recommendations.
•
October 2011–April 2012. VA declined DOD’s requests to discuss
care coordination and case management policy issues during this
period, according to DOD and VA senior officials, because VA had
established its own task force to conduct an internal review of its care
coordination and case management activities, including the FRCP. 62
After completing its initial assessment, VA briefed WWCTP officials on
the process it was using to review its care coordination and case
management activities, but chose not to discuss realignment of the
FRCP and RCP at that time, according to DOD officials who attended
this briefing. Instead, the VA Chief of Staff said that he approached
the Army’s Warrior Transition Command—which has the largest
number of recovering servicemembers—to propose developing
guidelines for better integrating Army’s wounded warrior program with
the FRCP, including identifying when the Army’s wounded warrior
programs should refer a recovering servicemember to the FRCP, and
replacing multiple care coordination plans with a single,
comprehensive planning document. However, a high-level DOD
official criticized this initiative as a tactic to minimize central input from
61
The Recovery Warrior Task Force also reported that DOD has partially addressed an
additional 6 recommendations and noted that 13 recommendations remain open.
62
Responding to a recommendation of a consulting firm that advised VA on its care
coordination and case management policy, the VA Chief of Staff directed that VA conduct
a department-wide inventory and review of its existing care coordination and case
management programs and personnel.
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the Office of the Secretary of Defense and pointed out that this effort
would result in an agreement with only a single military branch. In
contrast, VA’s Chief of Staff told us that VA took this approach in the
hope that if an agreement could be reached with Army, the other
military branches would follow suit.
More recently, in May 2012, VA and DOD developed a new task force,
the VA/DOD Warrior Care and Coordination Task Force, which
represents an effort to comprehensively address problems caused by the
lack of integration between DOD’s and VA’s care coordination and case
management programs. The task force has developed recommendations
that are intended to achieve a coordinated, interdepartmental approach to
care coordination and case management programs, according to a task
force official. On August 10, 2012, the task force presented the following
recommendations to the Joint Executive Council for its consideration:
•
establish and charter an interagency governance structure
responsible for coordinating VA and DOD policy,
•
establish and charter an interagency care coordination community of
practice, 63
•
align the FRCP to function in a consultant and resource-facilitator role,
•
clarify the lead coordinator role and responsibilities for executing a
recovering servicemember’s comprehensive plan,
•
identify the business requirements for technical tools to support the
interagency comprehensive plan, and
•
accelerate existing information-sharing efforts for care coordination.
The Joint Executive Council provisionally approved the six
recommendations, but withheld final approval pending receipt of
additional information from the task force, such as an estimate of
resources required to implement the recommendations, as well as
details of the proposed interagency governance structure. The Joint
63
Communities of practice are groups of people who engage, through regular interaction
with one another, in a process of collective learning in a shared domain of human
endeavor.
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Executive Council instructed the task force to present the additional
information to them in another decision briefing, which was scheduled for
September 20, 2012. Absent final approval from the Joint Executive
Council, the task force’s next step was to hold a status briefing for the
DOD and VA Secretaries on September 10, 2012, to discuss the task
force’s recommended course of action for care coordination.
Given the inability of past task forces to effect changes that better align
DOD and VA care coordination and case management policies, it is too
soon to determine the full effect of the departments’ efforts to manage
care coordination services regarding outcomes for recovering
servicemembers and veterans. Although VA and DOD appear to be
moving in a positive direction on care coordination, notable barriers
remain:
•
There is concern as to whether the Joint Executive Council can
effectively lead the effort to realign VA’s and DOD’s care coordination
policy. Some high-ranking and cognizant DOD officials we talked with
expressed concerns that the recently merged Joint Executive Council
may not have the capability to effectively monitor the actions taken by
DOD and VA to implement the task force’s recommendations. Some
officials we talked with viewed the council as taking too long to resolve
issues due to both the infrequency of its meetings 64 and the difficulties
DOD and VA members have in agreeing with one another.
•
Following approval of its recommended course of action, task force
documents indicate that a detailed plan will be completed by July
2013. VA’s task force cochair stated that some aspects of the planned
changes could take years to implement, particularly as they transition
existing enrollees of programs affected by significant revisions. For
example, VA intends to conduct a case-by-case review of every
FRCP enrollee before modifying the FRCP to function in a consultant
and resource-facilitator role, according to VA’s Task Force cochair.
•
One of the most fundamental challenges to resolving care
coordination problems is the issue of obtaining the cooperation of the
military services to implement a new approach to care coordination
and case management, especially in light of past difficulties of working
in concert with DOD and VA programs and policies. DOD and VA
64
The Joint Executive Council meets on a bimonthly basis.
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leadership officials stated that even if new solutions and policies were
to be approved by the departments, changes would be made only if
the individual military services implement the new policies as directed
by the Secretary of Defense. Several DOD and VA officials identified
concurrence and support of the military services as the most difficult
element to achieve. Ultimately, the military services’ compliance with
the departments’ agreed-upon strategy for care coordination and case
management programs will determine how seamlessly recovering
servicemembers and veterans will be able to navigate the recovery
care continuum.
Conclusions
The deficiencies exposed at Walter Reed in 2007 served as a catalyst
compelling DOD and VA to address a host of problems that complicate
the course of a wounded, ill, and injured servicemember’s recovery,
rehabilitation, and return to active duty or civilian life. We believe strongly
and have reported already that fixing the long-standing and complex
problems highlighted in the wake of the Walter Reed media accounts as
expeditiously as possible is critical to ensuring high-quality care for
returning servicemembers and veterans. We continue to believe that the
departments’ success ultimately depends on sustained attention,
systematic oversight, and sufficient resources from both DOD and VA.
However, this has not yet occurred, and as a result, after 5 years,
recovering servicemembers and veterans are still facing problems as they
navigate the recovery care continuum, including access to some of the
programs designed to assist them. The transition period from DOD’s to
VA’s health care system is particularly critical, as servicemembers
continue to experience delays in the disability evaluation system and the
departments continue to use methods other than a common information
technology system to share servicemembers’ health information. Until
these problems are resolved, recovering servicemembers and veterans
may still face difficulties getting the services they need to maximize their
potential when they return to active duty or transition to civilian life.
Initially, departmental leadership exhibited focus and commitment—
through the Senior Oversight Committee—to addressing problems related
to case management and care coordination, disability evaluation systems,
and data sharing between DOD and VA. However, over time, waning
leadership attention, a failure to oversee critical wounded warrior
functions and programs, limited resources, and the inability to achieve a
collaborative environment— particularly with care coordination—have
impeded the departments’ ability to fully resolve these problems. A key
element in resolving current care coordination issues in particular is
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eliciting the cooperation of the military services, which are responsible for
implementing various wounded warrior programs and ensuring that these
programs operate as intended—which has sometimes not been the case,
as with the RCP. Also, absent clear direction and central oversight and
accountability among the military services’ wounded warrior programs,
true cooperation and program effectiveness may be in jeopardy.
We believe that at the heart of the problem is the need for strong and
unwavering leadership to bring about changes that best serve our
nation’s recovering servicemembers and veterans. This leadership should
be united across both DOD and VA and centered on the individual
servicemember’s or veteran’s recovery. Many task forces—including the
VA/DOD Warrior Care and Coordination Task Force and the Recovering
Warrior Task Force—have already attempted to bring a spirit of
cooperativeness and clear direction and purpose among the different
programs providing services to this population. However, to date, these
efforts have not fully resolved key issues, and our nation’s recovering
servicemembers and veterans continue to face obstacles and challenges,
especially as they transition from DOD’s to VA’s health care system.
Certainly, the fluidity and focus of the departments’ leadership over the
last several years, especially related to care coordination, have added to
the challenges of developing consistent policy, effective oversight, and
mechanisms to monitor progress and hold programs accountable. The
departments have recently taken steps to improve problems related to
care coordination, disability evaluations, and the electronic sharing of
health records, through concerted efforts to coordinate on policy, increase
staffing resources, and provide control over the budget, respectively.
However, it is too early to determine the effectiveness of these efforts,
and sustained leadership attention will be critical to their success. The
need to fully resolve remaining problems is urgent as there will be an
increasing demand for services from both DOD and VA as the current
conflicts come to an end. If not resolved now, these same problems will
persist into the future for recovering servicemembers and veterans.
Recommendations for
Executive Action
To ensure that servicemembers have equitable access to the military
services’ wounded warrior programs, including the RCP, and to establish
central accountability for these programs, we recommend that the
Secretary of Defense establish or designate an office to centrally oversee
and monitor the activities of the military services’ wounded warrior
programs to include the following:
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•
Develop consistent eligibility criteria to ensure that similarly situated
recovering servicemembers from different military services have
uniform access to these programs.
•
Direct the military services’ wounded warrior programs to fully comply
with the policies governing care coordination and case management
programs and any future changes to these policies.
•
Develop a common mechanism to systematically monitor the
performance of the wounded warrior programs—to include the
establishment of common terms and definitions—and report this
information on a biannual basis to the Armed Services Committees of
the House of Representatives and the Senate.
To ensure that persistent challenges with care coordination, disability
evaluation, and the electronic sharing of health records are fully resolved,
we recommend that the Secretaries of Defense and Veterans Affairs
ensure that these issues receive sustained leadership attention and
collaboration at the highest levels with a singular focus on what is best for
the individual servicemember or veteran to ensure continuity of care and
a seamless transition from DOD to VA. This should include holding the
Joint Executive Council accountable for
Agency Comments
and Our Evaluation
•
ensuring that key issues affecting recovering servicemembers and
veterans get sufficient consideration, including recommendations
made by the Warrior Care and Coordination Task Force and the
Recovering Warrior Task Force;
•
developing mechanisms for making joint policy decisions;
•
involving the appropriate decision-makers for timely implementation of
policy; and
•
establishing mechanisms to systematically oversee joint initiatives and
ensure that outcomes and goals are identified and achieved.
DOD and VA reviewed a draft of this report and provided comments,
which are reprinted in appendixes III and IV. DOD and VA also provided
technical comments, which we incorporated as appropriate.
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DOD concurred with specific components of our first recommendation
regarding the establishment of central accountability for the military
services’ wounded warrior programs. In particular, DOD agreed that a
single office should have oversight responsibility for the military services’
wounded warrior programs and that these programs should fully comply
with the policies governing care coordination and case management
programs and any future changes to these policies.
However, DOD only partially concurred with other components of our first
recommendation—that DOD develop consistent eligibility criteria for
enrollment in wounded warrior programs and that DOD establish a
common mechanism to systematically monitor the performance of these
programs. In its comments, DOD explained that the three military service
Secretaries should have the ability to control entrance criteria into their
wounded warrior programs and added that it does not believe that
differences in eligibility criteria for these programs results in noticeable
differences in access to these programs by recovering servicemembers
or their families. DOD did not offer a rationale, however, as to why the
military service Secretaries should unilaterally determine eligibility criteria
for their wounded warrior programs, other than to suggest that flexibility is
important and necessary. Moreover, as we have reported, DOD does not
systematically assess or monitor these programs across the department,
and as a result, we believe that DOD has no basis to assert that there are
no noticeable differences in access to these programs. Overall, we
believe that similarly situated wounded, ill, and injured servicemembers
should be given the same access to wounded warrior programs and the
assistance these programs provide, regardless of their branch of military
service.
With respect to developing a common mechanism to systematically
monitor the performance of the wounded warrior programs, DOD
responded that the Interagency Care and Coordination Committee will
conduct an inventory of all wounded warrior programs to identify
duplication and areas for gaining efficiencies. In commenting on our
recommendation to also report its performance information on the
wounded warrior programs to the Armed Services Committees on a
biannual basis, DOD stated that the department reports progress through
the Joint Executive Council’s annual strategic planning report and any
additional reporting would be redundant and of limited value. We
disagree. The Joint Executive Council’s strategic planning and annual
reports focus on joint efforts between the departments and do not report
on the performance of the military services’ wounded warrior programs.
Therefore, we do not believe that the performance information on the
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wounded warrior programs would be redundant or of limited value given
that the department itself is currently unable to systematically determine
how well these programs are functioning. As we reported, one of the key
problems hindering a department-wide assessment of these programs is
the lack of common terms and definitions used by the military services.
Although DOD acknowledges that this is an issue, it asserts that it has
instituted some common definitions through the Senior Oversight
Committee and through its instruction for the RCP and that it will work
towards a common understanding and use of these approved definitions.
Although we are aware of efforts to define some terms, on the basis of
our work, it does not appear that the military services are using them
consistently. Therefore, substantial progress towards a common
understanding and use will be critical to the department’s ability to
oversee these programs.
DOD did not respond directly to our recommendation for developing a
common mechanism for performance measurement, which we found is
not systematically conducted across the wounded warrior programs.
During our collection of performance data from the wounded warrior
programs, we found that the programs vary in their ability to report
performance outcome measures on the basis of what each program
chooses to track. In addition, we found that some of the programs had
difficulty reporting basic data, such as enrollment numbers, and only
compiled these data following our request—sometimes taking about
5 months to do so. Lastly, our recommendation is consistent with the call
of the Interagency Care and Coordination Committee that the military
programs develop more useful quantitative and qualitative metrics that
would effectively demonstrate their performance. Until DOD takes the
necessary steps to assess these programs department-wide, it will never
know with certitude whether these programs are meeting the needs of its
recovering servicemember population.
DOD and VA both concurred with our second recommendation that the
departments ensure that care coordination, disability evaluation, and
electronic health record sharing receive sustained leadership attention
and collaboration at the highest levels, with a singular focus on what is
best for the individual servicemember or veteran to ensure continuity of
care and a seamless transition from DOD to VA.
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In addition to its comments on our recommendation, VA asserted that the
care coordination challenges facing both departments are broader and
more complex than issues concerning just the FRCP and RCP and that
our overall analysis and conclusions are over simplified. VA stated that
through its recently formed task force, both departments identified over
40 programs that provide some level of coordination or management of
care and services across the continuum of care and acknowledged that
there is no common operational picture that facilitates collaborative
planning or situational awareness. We agree that the care coordination
challenges are broader and more complex than the FRCP and RCP.
Specifically, in October 2011, we recommended that the departments
strengthen functional integration across all care coordination and case
management programs to reduce redundancy and overlap. 65 Similarly,
our current recommendation is broad and does not focus exclusively on
these two programs as our review also included other programs, such as
the military services’ wounded warrior programs, VA’s Liaison for
Healthcare Program, and VA’s OEF/OIF/OND Care Management
Program. The scope of our review was directed by Congress, who
required us to report on the progress DOD and VA in implementing the
programs involved with the care, management, and transition of
wounded, ill, and injured servicemembers that they established. Our
specific discussion of the FRCP and RCP served to illustrate, until
recently, a continued lack of collaboration between the departments to
better align these programs and better serve recovering servicemembers
and veterans. Furthermore, during detailed discussions with top-level VA
and DOD officials, they focused on the FRCP and RCP issue as the main
sticking point in achieving coordination and cooperation among the two
departments with respect to care coordination and case management.
We are encouraged that the departments are now taking steps to identify
all programs that need better alignment and integration. However, as we
have stated, the key to resolving this and other problems is the need for
strong and unwavering leadership that is united across both departments
and focused on the individual servicemember’s or veteran’s recovery.
65
GAO-12-129T.
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VA also suggested further clarifications to our report.
•
VA suggested that we clarify that while the VA Liaison for Healthcare
Program facilitates the transfer of recovering servicemembers from
DOD’s to VA’s health care system, it is a DOD or VA treatment team
that determines if the servicemember is medically ready to begin the
transition process. VA also suggested that we add that that the
OEF/OIF/OND Care Management Program screens all returning
combat veterans for case management services. We incorporated
VA’s suggested changes.
•
VA disagrees with a DOD-attributed statement that the Joint
Executive Council historically has not driven policy decision making
and that, at times, decisions were taken directly to the DOD and VA
Secretaries for resolution. The statement that we attribute to the DOD
official relates to the period prior to the integration of the Senior
Oversight Committee with the Joint Executive Council. As mentioned
in the report, it is too early to ascertain whether the newly merged
Joint Executive Council will be able to make decisions and drive policy
changes in DOD and VA.
•
VA provided clarification about how the Joint Executive Council is
currently providing oversight and accountability for wounded warrior
issues that were once addressed by the Senior Oversight Committee.
We recognize the effort that the Joint Executive Council is now
making to track wounded warrior issues, including the integrated
disability evaluation system and care coordination. However, we have
not had the opportunity to review this tracking mechanism now in
place to comment on its effectiveness.
•
VA asserts that the size of the overlap between the FRCP and RCP
population is fairly small. Although the number of seriously injured
servicemembers may be comparatively small, this situation has been
and continues to be a major concern in that these individuals and their
families represent a highly vulnerable population. Further, during our
review, one high-level DOD official we spoke with characterized the
FRCP/RCP overlap as the most difficult policy issue to resolve. While
we understand that DOD and VA now intend to harmonize care
coordination policies within a broader context of interdepartmental
care coordination and case management practice, many of the
proposed revisions—including the role to be played by the FRCP—
are neither fully developed nor implemented by the separate DOD and
VA programs at this time.
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GAO-13-5 Recovering Servicemembers and Veterans
•
In our report, we explain that VA declined DOD’s requests to discuss
care coordination and case management policy issues—for the better
part of 1 year—on the basis that VA was conducting an internal
review of its care coordination and case management activities. In its
comments, VA stated that the use of the word “decline” is misleading,
and suggested that we change our text to state that VA asked DOD to
defer collaboration until the internal review was conducted. Despite
VA’s characterization that our statement is misleading, we maintain
that this finding was based on remarks made by high-level DOD
officials that were subsequently corroborated by senior VA officials.
We are sending copies of this report to appropriate congressional
committees, the Secretary of Defense, the Secretary of Veterans Affairs,
and other interested parties. The report also is available at no charge on
GAO’s website at http://www.gao.gov.
If you or your staff members have any questions about this report, please
contact me at (202) 512-7114 or williamsonr@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. Key contributors to this report are listed in
appendix V.
Randall B. Williamson
Director, Health Care
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GAO-13-5 Recovering Servicemembers and Veterans
List of Committees
The Honorable Carl Levin
Chairman
The Honorable John McCain
Ranking Member
Committee on Armed Services
United States Senate
The Honorable Patty Murray
Chairman
The Honorable Richard Burr
Ranking Member
Committee on Veterans’ Affairs
United States Senate
The Honorable Daniel Inouye
Chairman
The Honorable Thad Cochran
Ranking Member
Subcommittee on Defense
Committee on Appropriations
United States Senate
The Honorable Tim Johnson
Chairman
The Honorable Mark Kirk
Ranking Member
Subcommittee on Military Construction, Veterans Affairs,
and Related Agencies
Committee on Appropriations
United States Senate
The Honorable Howard McKeon
Chairman
The Honorable Adam Smith
Ranking Member
Committee on Armed Services
House of Representatives
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The Honorable Jeff Miller
Chairman
The Honorable Bob Filner
Ranking Member
Committee on Veterans’ Affairs
House of Representatives
The Honorable C.W. Bill Young
Chairman
The Honorable Norman Dicks
Ranking Member
Subcommittee on Defense
Committee on Appropriations
House of Representatives
The Honorable John Culberson
Chairman
The Honorable Sanford Bishop
Ranking Member
Subcommittee on Military Construction, Veterans Affairs,
and Related Agencies
Committee on Appropriations
House of Representatives
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Appendix I: Enrollment and Populations for
Select Department of Defense and
Department of Veterans Affairs Programs
Appendix I: Enrollment and Populations for
Select Department of Defense and Department
of Veterans Affairs Programs
Both the Department of Defense (DOD) and the Department of Veterans
Affairs (VA) operate care coordination 1 and case management 2 programs
designed to assist servicemembers and veterans as they navigate the
recovery care continuum, from acute medical treatment and stabilization,
through rehabilitation, to reintegration—either back to active duty or to the
civilian community as a veteran. This appendix describes selected DOD
and VA programs and includes data on enrollment and population
characteristics as well as the type of information each program tracks on
referrals.
DOD Wounded
Warrior Programs
Within DOD, each military service has established its own wounded
warrior program or a complement of programs 3 to assist wounded, ill, and
injured servicemembers during their recovery and rehabilitation, and to
help with the transition back to active duty or to civilian life. 4 Wounded
warrior programs range in size from the largest, the Army’s Warrior
Transition Units and Community-Based Warrior Transition Units, with
18,762 enrollees served in fiscal year 2011, to the smallest, the Navy
Safe Harbor Program, with 784 enrollees served in fiscal year 2011. (See
table 4 for a list of the DOD wounded warrior programs and enrollment for
fiscal year 2011.)
1
According to the National Coalition on Care Coordination, care coordination is a clientcentered, assessment-based interdisciplinary approach to integrating health care and
social support services in which an individual’s needs and preferences are assessed, a
comprehensive care plan is developed, and services are managed and monitored by an
identified care coordinator.
2
According to the Case Management Society of America, case management is defined as
a collaborative process of assessment, planning, facilitation, and advocacy for options and
services to meet an individual’s health needs through communication and available
resources to promote high quality, cost-effective outcomes.
3
Military services operate multiple programs that are specialized to serve different
populations, such as the severely wounded or surviving family members. For example,
within the Air Force’s Warrior and Survivor Care Program, the Air Force operates three
distinct programs: (1) the Air Force Wounded Warrior Program to serve those who were
injured in combat; (2) the Air Force Recovery Care Program to serve other seriously and
severely wounded, ill, and injured; and (3) the Air Force Survivor Assistance Program, to
serve surviving family members or caregivers of wounded, ill, and injured
servicemembers.
4
For the purpose of this appendix we will be discussing seven of the case management
and care coordination programs established by the military services to assist recovering
servicemembers and veterans with recovery, rehabilitation, and transition either back to
military service or to civilian life.
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Appendix I: Enrollment and Populations for
Select Department of Defense and Department
of Veterans Affairs Programs
Table 4: Military Services’ Wounded Warrior Programs: Enrollment for Fiscal Year 2011
Military services’ wounded warrior program
Number enrolled, as of fiscal year 2011
Army
Army Warrior Care and Transition Program: Warrior Transition Units and
a,b
Community-Based Warrior Transition Units
Army Warrior Care and Transition Program: Army Wounded Warrior Program
18,762
b
9,738
Navy/Coast Guard
Navy Safe Harbor Program
c
784
Air Force
d
Air Force Wounded Warrior Program
1,386
Air Force Recovery Care Program
1,804
Marine Corps
e,f
Marine Corps Wounded Warrior Regiment
United States Special Operations Command
2,155
g
United States Special Operations Command’s Care Coalition
4,570
Source: GAO analysis of military services’ wounded warrior program information.
a
Enrollment data include servicemembers who were in the Army Warrior Care and Transition
Program at any point during the fiscal year, not the population on a specific date.
b
Enrollees may include servicemembers who are dually enrolled in the Army Warrior Care and
Transition Program and Army Wounded Warrior Program.
c
Enrollment numbers represent all enrollees being served by the program as of December 31, rather
than as of the end of each fiscal year.
d
Servicemembers may be dually enrolled in the Air Force Wounded Warrior Program and the Air
Force Recovery Care Program. The enrollment data presented here only reflect servicemembers who
are enrolled in the Air Force Wounded Warrior Program.
e
According to a Wounded Warrior Regiment official, the Wounded Warrior Regiment does not have
“enrollees,” rather the program assigns and attaches Marines to the program.
f
Total enrollment does not include Wounded Warrior Regiment enrollees who are not assigned or
attached to a Wounded Warrior Regiment site. Many wounded, ill, and injured Marines are supported
by the Wounded Warrior Regiment while remaining with their parent unit.
g
Enrollees of the United States Special Operations Command’s Care Coalition Recovery Program
may also be enrolled in a military service’s wounded warrior program on the basis of their branch of
service, but the United States Special Operations Command’s Care Coalition Recovery Program
takes the lead for providing nonclinical case management.
Programs differ in their organization and function. For example, two of the
wounded warrior programs—the Army’s Warrior Transition Units and the
Marine Corps Wounded Warrior Regiment—are organized under
separate military commands, which means that wounded, ill, and injured
servicemembers enrolled in these programs may be removed from their
parent units or commands and assigned or attached to a separate unit or
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of Veterans Affairs Programs
regiment that provides command and control 5 over the recovering
servicemember as well as administrative support. These servicemembers
may be housed in separate barracks while receiving medical care and
waiting to transition back to active duty or civilian life. The other wounded
warrior programs do not assign or attach servicemembers to a separate
command structure, but provide services while recovering
servicemembers remain with their parent units. The services provided by
the wounded warrior programs also vary. A servicemember may receive
either case management or care coordination services or both, depending
on how the military service’s wounded warrior program is structured. For
example, the Navy Safe Harbor Program only provides care coordination
services and does not have a case management component, whereas
the Marine Corps Wounded Warrior Regiment provides all
servicemembers with both case management and care coordination
services. A further distinction is whether or not a program serves veterans
as well as servicemembers. For example, the Army Warrior Transition
Units do not serve veterans, but eligible veterans are served through the
Army Wounded Warrior Program. The remainder of the wounded warrior
programs continue to provide support to any enrollee who needs services
even after the enrollee has transitioned to veteran status.
Army Warrior Care and
Transition Program
The Army’s Warrior Care and Transition Program, which was established
in May 2007, 6 consists of two components that support the recovery
process for wounded, ill, and injured servicemembers—the Warrior
Transition Units 7 and the Army Wounded Warrior Program. The Army
operates a number of warrior transition units located at Army installations
across the country. Recovering servicemembers who are attached or
assigned to a warrior transition unit generally are housed in barracks and
receive medical care, rehabilitative services, professional development
and clinical and nonclinical case management services in order to help
5
DOD defines command and control as the exercise of authority and direction by a
properly designated commander over assigned and attached forces in the
accomplishment of the mission.
6
The program was originally named the Army Medical Action Plan.
7
Warrior Transition Units are technically an Army brigade, battalion, or company that
provides command and control, administrative support, primary care and case
management and other services to promote readiness of soldiers and family to transition
back to active duty or to civilian life. For the purposes of this report, we are categorizing it
as a wounded warrior program.
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of Veterans Affairs Programs
them in their transition back to active duty or to the civilian community.
Army Warrior Transition Units vary in size and functionality, including
community-based warrior transition units, 8 which primarily serve Reserve
Component servicemembers. 9 In fiscal year 2011, there were a total of
14,906 recovering servicemembers assigned or attached to 29 warrior
transition units and 3,856 recovering servicemembers assigned or
attached to 10 community-based warrior transition units. (See table 5.)
According to Army policy, recovering servicemembers assigned or
attached to the units are expected to require 6 months or more of
rehabilitative care or require complex medical management.
The Army Wounded Warrior Program 10 was established in April 2004 to
assist severely wounded, ill, and injured servicemembers, their families,
and caregivers. Army Wounded Warrior Program enrollees are assigned
an Advocate who provides nonclinical care coordination services, which
include assisting enrollees with benefit information, career guidance,
finances, and the integrated disability evaluation system (IDES) process.
Recovering servicemembers are eligible for Army Wounded Warrior
Program services if they have, or are expected to receive, an Army
disability rating of 30 percent or greater in one or more specific categories
or a combined rating of 50 percent or greater for conditions that are the
result of combat or are combat-related. The most severely wounded, ill, or
injured servicemembers who are assigned to warrior transition units are
also enrolled in the Army Wounded Warrior Program. The Army Wounded
Warrior Program also provides services to veterans. In fiscal year 2011,
nearly three-fourths of the population (6,953) were veterans. (See
table 6.)
8
The Community-based Warrior Transition Unit Program allows servicemembers to live at
home and perform duty at a location near home while receiving medical care.
9
Warrior transition units and community-based warrior transition units serve Active
Component servicemembers as well as servicemembers in National Guard and Reserve
Components, but do not serve veterans.
10
The Army Wounded Warrior Program was originally named the Disabled Soldier
Support System.
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of Veterans Affairs Programs
Table 5: Army Warrior Care and Transition Program Enrollment Populations and Characteristics, Fiscal Years 2008 through
2011
Fiscal year
2008
2009
2010
2011
20,878
19,238
18,647
18,762
13,558
11,771
9,560
9,160
4,761
4,839
5,860
5,857
2,559
2,628
3,227
3,745
2,523
2,033
1,788
1,984
18,355
17,205
16,859
16,778
4,366
4,279
4,664
5,349
5,125
5,938
4,027
3,448
146
200
159
148
20,878
19,238
18,647
18,762
18,038
16,203
14,921
14,906
13,511
11,686
9,456
9,058
2,864
2,807
3,336
3,354
1,663
1,710
2,129
2,494
2,231
1,798
1,569
1,760
15,807
14,405
13,352
13,146
3,613
3,653
3,803
4,259
4,706
5,445
3,700
3,167
139
184
146
135
2,840
3,035
3,726
3,856
47
85
104
102
1,897
2,032
2,524
2,503
896
918
1,098
1,251
Program enrollment for Warrior Transition Units and
Community-Based Warrior Transition Units
Total enrollment
a,b
Active Duty
National Guard
Reservists
c
c
Population characteristics
Enrollees with combat-related conditions
d
e
Enrollees with non-combat-related conditions
Enrollees who left the program
f
Returned to active duty
Transitioned to veteran status
Left for other reasons
g
h
Referrals
i
Total number of servicemembers referred to the program
Warrior Transition Unit enrollment
Total enrollment in Warrior Transition Units
a,b
Active Duty
National Guard
Reservists
c
c
Population characteristics
Enrollees with combat-related conditions
d
e
Enrollees with non-combat-related conditions
Enrollees who left the program
f
Returned to active duty
Transitioned to veteran status
Left for other reasons
g
h
Community-Based Warrior Transition Unit enrollment
Total enrollment in Community-Based Warrior Transition Units
Active Duty
National Guard
Reservists
c
c
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Appendix I: Enrollment and Populations for
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of Veterans Affairs Programs
Fiscal year
2008
2009
2010
2011
Population characteristics
Enrollees with combat-related conditions
d
e
Enrollees with non-combat-related conditions
292
235
219
224
2,548
2,800
3,507
3,632
753
626
861
1,090
419
493
327
281
7
16
13
13
Enrollees who left the program
f
Returned to active duty
Transitioned to veteran status
Left for other reasons
g
h
Source: GAO analysis of Army Warrior Care and Transition Program data.
Notes: The Army Warrior Care and Transition Program’s Warrior Transition Units and CommunityBased Warrior Transition Units serve Active, Guard, and Reserve Component servicemembers. The
program does not serve veterans.
a
Enrollment data include servicemembers who were in the Army Warrior Care and Transition
Program at any point during the fiscal year, not the population on a specific date.
b
Enrollees may include servicemembers who are dually enrolled in the Army Warrior Care and
Transition Program and the Army Wounded Warrior Program.
c
National Guard and Reservists enrolled in the Army Warrior Care and Transition Program must be
on active-duty orders in order to participate in the program.
d
Enrollees with combat-related conditions only include those enrollees medically evacuated from a
combat zone with identified battle injuries. Other combat-related conditions, such as posttraumatic
stress disorder, may not have required medical evacuation from a combat zone and therefore would
not be captured in the data provided. In addition, prior battle injuries not related to the
servicemember’s current medical diagnosis would also be excluded from the data. Battle injury is
defined as damage or harm sustained by personnel during or as a result of battle conditions.
e
Enrollees with non-combat-related conditions include all enrollees who were not medically evacuated
from a combat zone and those who are identified as having nonbattle injuries.
f
Enrollees who exit the program by returning to duty also include Guard or Reserve Components who
are released from active duty, but not medically separated from military service.
g
Enrollees who transition to veteran status include only enrollees who are medically separated from
military service.
h
Enrollees are considered to have left the Army Warrior Care and Transition Program’s Warrior
Transition Units for “other” reasons, including death or as a result of military legal actions. This
category also includes those enrollees with incomplete information about why they left the program.
i
According to Army Warrior Care and Transition Program officials, the program only tracks referral
information for program enrollees. Therefore, the program does not have data on servicemembers
who were referred, but never enrolled into the program.
j
The Army’s Community-Based Warrior Transition Units are populated only by servicemembers who
transfer to the Community-Based Units from their original assignment to a Warrior Transition Unit.
According to Army Warrior Care and Transition Program officials, the first 60 days of recovery are
typically spent in a Warrior Transition Unit. After the initial recovery period, a decision is made about
whether the servicemember should be transferred to a community-based unit. Data provided in the
table reflect the most recent location recorded for each enrollee.
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of Veterans Affairs Programs
Table 6: Army Wounded Warrior Program Enrollment Populations and Characteristics, Fiscal Years 2008 through 2011
Fiscal year
2008
2009
2010
2011
3,813
6,473
8,454
9,738
2,037
3,377
3,354
2,785
1,249
2,252
1,954
1,210
562
794
985
1,091
Program enrollment for Army Wounded Warrior Program
Total enrollment
a,b
Servicemembers
Active Duty
National Guard
Reservists
c
c
Veterans
226
331
415
484
1,776
3,096
5,100
6,953
3,233
5,503
7,082
8,001
544
875
1,104
1,184
36
95
268
553
117
80
59
47
958
1,574
1,539
1,100
10
24
21
3
3,106
4,199
3,993
3,364
2,037
3,377
3,354
2,785
Population characteristics
Enrollees with combat-related conditions
Enrollees with non-combat-related conditions
d
Enrollees with conditions not classified as either combat- or non-combat-related
Enrollees who changed duty status or left the program
e
Returned to active duty
Transitioned to veteran status
Left for other reasons
f
g
Referrals and assists
Total number of servicemembers referred to the program
Servicemembers referred and enrolled in the program
Servicemembers referred and assisted, but not enrolled in the program
h
Total number of veterans referred to the program
Veterans referred and enrolled in the program
Veterans referred and assisted, but not enrolled in the program
969
822
639
579
2,568
3,617
5,554
7,291
1,776
3,096
5,100
6,953
792
521
454
338
Source: GAO analysis of Army Wounded Warrior Program data.
a
Enrollment data include servicemembers and veterans who were served by the program at any point
during the fiscal year, not the population being served on a specific date.
b
Enrollees also may be enrolled in the Army’s Warrior Transition Units or Community-Based Warrior
Transition Units.
c
Enrollment is counted in this category only for National Guard and Reservists who were on active
duty orders during the designated fiscal year. According to Army Wounded Warrior Program officials,
National Guard and Reservists who were demobilized previous to the designated fiscal year are
considered veterans.
d
Enrollees considered to have “conditions not classified as either combat- or non-combat-related”
include enrollees who have yet to complete the physical disability evaluation process and therefore
do not have verification of whether or not their conditions are combat-related.
e
Army Wounded Warrior Program officials said that the program does not specifically track whether or
when an enrollee returns to active duty. However, data on duty status are available for those
enrollees who are also enrolled in the Army’s Warrior Transition Units or Community-Based Warrior
Transition Unit, as provided in the table.
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f
Army Wounded Warrior Program officials said that the program does not specifically track whether or
when an enrollee transitions to veteran status because it has no impact on enrollees’ eligibility for the
program and whether they leave the program. Rather, these data have been derived by the program
by counting the number of enrolled servicemembers who received a certificate of release or
discharge from active duty within each fiscal year.
g
Enrollees considered to have “left for other reasons” include those who died while enrolled in the
Army Wounded Warrior Program.
h
The data include those enrollees who were later found ineligible for the program and were
disenrolled, but assisted during their initial period of enrollment. These ineligible enrollees were not
included in the program’s count of total enrollees. Additionally, some servicemembers who were
referred to the Wounded Warrior Program and provided short-term, informal assistance are not
included in the data because they are not tracked by the program.
Navy Safe Harbor Program
The Navy Safe Harbor Program office was established in 2005. Over
time, this office expanded its reach and mission, and in 2008 the program
became responsible for nonclinical care coordination and oversight of all
severely (and high-risk nonseverely) wounded, ill, and injured Sailors and
Coast Guardsmen. 11 Recovering servicemembers enrolled in the program
are assigned to nonmedical care managers who are geographically
dispersed at major military treatment facilities and Veterans Affairs
polytrauma medical centers. The program’s nonmedical care managers
assist enrollees with services such as pay and personnel, legal, housing,
as well as education and training benefits. In addition, enrollees obtain
support from centrally located experts in transition and benefits
assistance, such as a liaison to the Department of Labor and a Navy Staff
Judge Advocate. Recovering servicemembers enrolled in the program are
enrolled for life and, if desired, receive support from Navy Safe Harbor
personnel after they transition to veteran status. (See table 7.)
11
According to Navy Safe Harbor Program officials, the program evolved from the Navy’s
preexisting Military Severely Injured Center & Casualty Office.
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of Veterans Affairs Programs
Table 7: Navy Safe Harbor Program Enrollment Populations and Characteristics, Fiscal Years 2008 through 2011
Fiscal year
2008
2009
2010
2011
255
434
576
784
Program enrollment for Navy Safe Harbor Program
Total enrollment
a
Servicemembers
144
236
271
391
Active Duty
77
129
152
254
Reservists
67
107
119
137
111
198
305
393
Enrollees with combat-related conditions
130
166
193
239
Enrollees with non-combat-related conditions
125
268
383
545
ND
113
b
142
Veterans
Population characteristics
Enrollees who changed duty status or left the program
Returned to active duty
ND
ND
Transitioned to veteran status
ND
91
Left for other reasons
b
338
0
0
0
1
304
296
370
475
Referrals and assists
Total number of servicemembers and veterans referred to the program
c
Servicemembers and veterans referred and enrolled in the program
255
179
142
208
Servicemembers and veterans referred and assisted, but not enrolled in the program
74
417
330
199
Servicemembers and veterans referred but not enrolled in or assisted by the program
0
0
2
73
Legend: ND indicates that no data are available.
Source: GAO analysis of Navy Safe Harbor Program data.
a
Enrollment numbers represent all enrollees being served by the program as of December 31, rather
than as of the end of each fiscal year.
b
According to a Navy Safe Harbor Program official, the database used to capture information about
the duty status of enrollees did not have the ability to track dates when servicemembers transitioned
to veteran status until the system was upgraded in 2010. At that point, the program moved all
enrollees who had previously medically retired to a veteran status. Therefore, the number of enrollees
who transitioned to veteran status in fiscal year 2010 includes both servicemembers who transitioned
to veteran status within the fiscal year and servicemembers who transitioned to veteran status during
the previous fiscal years.
c
The database used to capture referral information for the Navy Safe Harbor Program does not
distinguish servicemembers from veterans referred to the program. Rather, the referral information
provided for servicemembers also includes any veterans who were referred to the program.
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of Veterans Affairs Programs
Air Force Warrior and
Survivor Care Program
The Air Force Warrior and Survivor Care Program supports wounded, ill,
and injured servicemembers through its Air Force Wounded Warrior
Program and the Air Force Recovery Care Program. 12 The Air Force
Wounded Warrior Program was established in June 2005 to provide
nonclinical case management to Airmen, Air National Guard, and
Reserve Component servicemembers who have combat-related illnesses
or injuries. Each enrolled servicemember is assigned a nonmedical care
manager, who serves as an advocate for enrollees to obtain services
from agencies and organizations that support the needs of enrolled
servicemembers, their families and caregivers. The Air Force Wounded
Warrior Program continues to provide services to enrollees once they
transition to veteran status. (See table 8.)
The Air Force Recovery Care Program was established in November
2008 to provide nonclinical care coordination services for seriously ill and
injured Airmen, Air National Guard, and Reserve Component
servicemembers. Each enrolled servicemember is assigned a care
coordinator who oversees the coordination of services and assists
enrollees’ with nonclinical needs, such as employment and benefits.
These care coordinators also work with enrolled servicemembers to
develop their recovery plans and career goals. Enrollees who have
combat-related illness or injuries are concurrently enrolled in the Air Force
Wounded Warrior Program. For example, in fiscal year 2011, almost 300
Air Force Recovery Care Program enrollees were also either tracked or
actively assisted by the Air Force Wounded Warrior Program. (See
table 9.)
12
The Air Force Warrior and Survivor Care Program’s Survivor Assistance Program
primarily provides services to the families of wounded, ill, and injured servicemembers.
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of Veterans Affairs Programs
Table 8: Air Force Wounded Warrior Program Enrollment Populations and Characteristics, Fiscal Years 2008 through 2011
Fiscal year
2008
2009
2010
2011
194
451
836
1,386
Program enrollment for Air Force Wounded Warrior Program
Total enrollment
a
Servicemembers
Active Duty
National Guard
Reservists
Veterans
160
388
703
1,143
103
256
463
783
32
60
123
194
25
72
117
166
34
63
133
243
187
442
804
1,327
7
9
32
59
4
22
65
128
157
329
532
786
146
357
724
1,176
Population characteristics
Enrollees with combat-related conditions
Enrollees with non-combat-related conditions
Enrollees who changed duty status or left the program
Returned to active duty
Transitioned to veteran status
Referrals and assists
Total number of servicemembers referred to the program
Servicemembers referred and enrolled in the program
145
337
645
1,071
b
1
20
79
105
Servicemembers referred but not enrolled in or assisted by the program
0
0
0
0
Servicemembers referred and assisted, but not enrolled in the program
Total number of veterans referred to the program
34
63
133
243
Veterans referred and enrolled in the program
34
63
133
243
Veterans referred and assisted, but not enrolled in the program
NA
NA
NA
NA
Veterans referred but not enrolled in or assisted by the program
0
0
0
0
Legend: NA indicates that the category is not applicable to the program.
Source: GAO analysis of Air Force Wounded Warrior Program data.
a
Servicemembers may be dually enrolled in the Air Force Recovery Care Program and the Air Force
Wounded Warrior Program. The enrollment data presented here only reflect servicemembers who are
enrolled in the Air Force Wounded Warrior Program.
b
According to Air Force Wounded Warrior Program officials, because the program only serves
servicemembers with combat-related conditions, most referrals come from casualty reports and the
disability evaluation process, where it is determined whether a servicemember’s wound, illness, and
injury are combat-related. Once the determination is made, servicemembers are enrolled into the
program.
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of Veterans Affairs Programs
Table 9: Air Force Recovery Care Program Enrollment Populations and Characteristics, Fiscal Years 2008 through 2011
Fiscal year
2008
2009
2010
2011
ND
ND
ND
1,804
Program enrollment for Air Force Recovery Care Program
Total enrollment
a
Servicemembers
ND
ND
ND
ND
National Guard
ND
ND
ND
ND
Reservists
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
251
Enrollees with combat-related conditions
ND
ND
ND
316
Enrollees with non-combat-related conditions
ND
ND
ND
782
Returned to active duty
ND
ND
ND
288
Transitioned to veteran status
ND
ND
ND
394
Left for other reasons
ND
ND
ND
ND
ND
ND
ND
1,804
Veterans
Others
b
Population characteristics
Enrollees who changed duty status or left the program
Referrals and assists
Total number of servicemembers referred to the program
Legend: ND indicates that no data are available.
Source: GAO analysis of Air Force Recovery Care Program data.
Notes: According to Air Force Recovery Care Program officials, the program did not routinely track
certain data about the program, because these data were not required to be collected by the DOD
policy that governs the program. In addition, the original Air Force Recovery Care program
requirements did not include provisions for data collection. The officials told us that a data-collection
tool is being developed and that requirements for data collection would be finalized by the beginning
of July 2012. The officials anticipate the new tool will be operational by January 2013.
a
Enrollees may also be enrolled in the Air Force’s Wounded Warrior Program.
b
The Air Force Recovery Care Program serves some servicemembers from other military services.
Marine Corps Wounded
Warrior Regiment
The Marine Corps established the Wounded Warrior Regiment in May
2007 to provide and facilitate assistance to wounded, ill, and injured
Marines and their family members throughout the recovery process. The
Wounded Warrior Regiment is a single command that oversees
nonmedical care for the total Marine force, including Active Duty,
Reserve, retired, and veteran Marines. The regiment enrolls Marines
regardless of whether they have combat- or non-combat-related
conditions. The regiment commands the operation of two wounded
warrior battalions and 14 detachments located at 12 principal military
treatment facilities and four Veterans Affairs polytrauma medical centers
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across the United States and overseas. A Marine enrolled in the regiment
can either stay with his or her parent unit and be supported by the
regiment, or be assigned or attached to one of the regiment’s battalions
and detachments, depending on their specific needs. Generally, Marines
who require more than 90 days of medical treatment or rehabilitation are
assigned or attached to a battalion or detachment. The District Injured
Support Cells Program is the component of the Wounded Warrior
Regiment that provides services to veterans. 13 District Injured Support
Coordinators are located at 30 sites across the United States to provide
support, including nonmedical care management to its enrollees. In fiscal
year 2011, the District Injured Support Coordinators provided support to
1,488 veterans. (See table 10.)
13
District Injured Support Coordinators may also provide support to Reserve and Active
Duty Marines in remote locations away from military or other federal resources.
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Appendix I: Enrollment and Populations for
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of Veterans Affairs Programs
Table 10: Marine Corps Wounded Warrior Regiment Enrollment Populations and Characteristics, Fiscal Years 2008 through
2011
Fiscal year
2008
2009
2010
2011
810
725
634
2,155
810
725
634
667
Active Duty
712
633
494
517
Reservists
98
92
140
150
ND
ND
ND
1,488
216
105
115
224
594
620
519
443
35
38
84
94
149
266
311
366
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
Program enrollment for Marine Corps Wounded Warrior Regiment
Total enrollment
a,b
Servicemembers
Veterans served through District Injured Support Coordinators
c
Population characteristics
Enrollees with combat-related conditions
d
e
Enrollees with non-combat-related conditions
Enrollees who changed duty status or left the program
Returned to active duty
Transitioned to veteran status
Left for other reasons
e
Referrals
f
Total number of servicemembers referred to the program
g
Total number of veterans referred to District Injured Support Coordinators
Legend: ND indicates that no data are available.
Source: GAO analysis of Marine Corps Wounded Warrior Regiment data.
a
According to a Wounded Warrior Regiment official, the Wounded Warrior Regiment does not have
“enrollees,” rather the program assigns and attaches Marines to the program.
b
Total enrollment does not include Wounded Warrior Regiment enrollees who are not assigned or
attached to a Wounded Warrior Regiment site. Many wounded, ill, and injured Marines are supported
by the Wounded Warrior Regiment while remaining with their parent unit.
c
The District Injured Support Coordinators provide outreach and services to Reserve and veteran
Marines located across the country.
d
The data in this category do not include Marines attached to the Wounded Warrior Regiment who
may have been wounded, fallen ill, or injured in a combat zone, but who were not medically
evacuated from a combat zone.
e
Although the Wounded Warrior Regiment was not able to provide data on the number of enrollees
who left the Wounded Warrior Regiment for reasons other than returning to duty or transitioning to
veteran status, according to a Wounded Warrior Regiment official, Marines attached to the Wounded
Warrior Regiment have left the program for other reasons such as death or as a result of military legal
actions taken against the Marine.
f
According to a Marine Corps Wounded Warrior Regiment official, although a policy exists requiring
referral information to be collected, the policy was not always enforced. According to this official, as of
fiscal year 2012, the data are routinely collected.
g
According to a Marine Corps Wounded Warrior Regiment official, the District Injured Support
Coordinators initially served veterans on an ad hoc basis, so referral information was not collected.
Page 67
GAO-13-5 Recovering Servicemembers and Veterans
Appendix I: Enrollment and Populations for
Select Department of Defense and Department
of Veterans Affairs Programs
United States Special
Operations Command’s
Care Coalition
The United States Special Operations Command established the Care
Coalition in August 2005 to track, support, and advocate for Special
Operations Force’s wounded, ill, and injured servicemembers regardless
of their duty status or whether their conditions are combat-related. (See
table 11.) All enrollees are assigned an Advocate and are entitled to
advocate services for life. Advocates assist enrollees with health care and
financial benefits, transition processes, and link enrollees with needed
government and nongovernment resources. Because the United States
Special Operations Command’s Care Coalition serves servicemembers
from across the military services, it serves as a liaison with, and
complements, the military services’ wounded warrior programs. United
States Special Operations Command’s Care Coalition enrollees are often
concurrently enrolled in their own military service’s wounded warrior
program. However, according to a Care Coalition official, the Care
Coalition serves as the lead program for case management and care
coordination for dually enrolled servicemembers.
Page 68
GAO-13-5 Recovering Servicemembers and Veterans
Appendix I: Enrollment and Populations for
Select Department of Defense and Department
of Veterans Affairs Programs
Table 11: United States Special Operations Command’s Care Coalition Enrollment Populations and Characteristics, Fiscal
Years 2008 through 2011
Fiscal year
2008
2009
2010
2011
b
3,447
4,570
1,594
1,741
2,475
3,518
National Guard
113
127
154
228
Reservists
193
196
206
232
654
722
838
893
152
192
262
287
1,693
1,803
2,415
2,879
736
839
1,256
1,859
Program enrollment for United States Special Operations Command’s Care Coalition
Total enrollment
a
2,277
Servicemembers
Veterans
Others
c
b
2,532
Population characteristics
Enrollees with combat-related conditions
d
d
Enrollees with non-combat-related conditions
Enrollees who changed duty status
e
Returned to active duty
Transitioned to veteran status
e
31
32
38
46
4
23
24
48
ND
ND
ND
ND
ND
ND
ND
ND
Referrals
f
Total number of servicemembers referred to the program
Total number of veterans referred to the program
f
Legend: ND indicates that no data are available.
Source: GAO analysis of United States Special Operations Command’s Care Coalition data.
a
Enrollees of the United States Special Operations Command’s Care Coalition Recovery Program
may also be enrolled in a military service’s wounded warrior program on the basis of their branch of
service, but the United States Special Operations Command’s Care Coalition Recovery Program
takes the lead for providing nonclinical case management.
b
According to a United States Special Operations Command’s Care Coalition official, because of a
change in the data system used to track enrollment, enrollment numbers provided for fiscal year 2008
include enrollees served by the program between October 1, 2007, and May 28, 2009. Enrollment
numbers provided for fiscal year 2009 include an additional 255 servicemembers and veterans who
enrolled in the program between May 28, 2009, and September 30, 2009.
c
Others enrolled include civilians, surviving family members, and records with unknown information.
According to a United States Special Operations Command’s Care Coalition official, the program
continues to provide and track services to surviving family members after an enrolled servicemember
or veteran has died.
d
According to a United States Special Operations Command’s Care Coalition official, data provided
on enrollees with either combat- or non-combat-related conditions also include some servicemembers
who were either killed in action or died while enrolled in the program, and therefore were excluded
from the total enrollment data. In addition, officials stated that the exact count for non-combat-related
conditions may not be accurate, due to inaccuracies in record keeping.
e
According to a United States Special Operations Command’s Care Coalition official, the program did
not begin tracking enrollee transition status and transition dates in an accessible format until January
2012. Therefore, information about the duty status and transition status is being updated by hand as
an individual record is reviewed by program personnel, and the information provided may not be
accurate.
Page 69
GAO-13-5 Recovering Servicemembers and Veterans
Appendix I: Enrollment and Populations for
Select Department of Defense and Department
of Veterans Affairs Programs
f
According to a United States Special Operations Command’s Care Coalition official, the program has
several methods of receiving referrals, but its primary source of referrals comes from casualty reports.
The program does not track referral information because the Care Coalition does not have a field in
its database to track this information. However, this official said that the Care Coalition could access
this information by contacting the military services.
VA Case Management
and Care
Coordination
Programs
VA operates a number of case management and care coordination
programs that provide assistance to recovering servicemembers and
veterans, including the Operation Enduring Freedom/Operation Iraqi
Freedom/Operation New Dawn (OEF/OIF/OND) Care Management
Program and the Federal Recovery Coordination Program (FRCP). 14
These two programs assist wounded servicemembers and veterans to
navigate the recovery care continuum.
OEF/OIF/OND Care
Management Program
The OEF/OIF/OND Care Management Program was established in March
2007 to provide case management to wounded, ill, and injured
servicemembers and veterans who screen positive for the need for case
management or request case management services. (See table 12).
Each of VA’s 152 Medical Centers (VAMC) has an OEF/OIF/OND Care
Management team in place to manage patient care activities and ensure
that servicemembers and veterans are receiving patient-centered,
integrated care and benefits. Members of the OEF/OIF/OND Care
Management team include: a Program Manager, Clinical Case Managers,
and a Transition Patient Advocate.
14
In addition, the Department of Veterans Affairs operates other dedicated programs and
systems of care including Polytrauma/Traumatic Brain Injury, Spinal Cord Injury and
Diseases, Visual Impairment, and Mental Health that provide specialized lifelong clinical
care and care management for these special cohorts of veterans.
Page 70
GAO-13-5 Recovering Servicemembers and Veterans
Appendix I: Enrollment and Populations for
Select Department of Defense and Department
of Veterans Affairs Programs
Table 12: Operation Enduring Freedom/Operation Iraqi Freedom/ Operation New Dawn (OEF/OIF/OND) Care Management
Program Enrollment Populations and Characteristics, Fiscal Years 2008 through 2011
Fiscal year
2008
Total enrollment
b
Servicemembers
2,463
c
Veterans
Others
a
d
a
2010
2011
7,048
49,145
50,255
2009
152
590
2,069
2,505
1,136
4,212
31,831
29,848
1,175
2,246
15,245
17,902
1,214
2, 470
7,165
6,898
212
676
3,115
3,188
200
880
4,820
4,072
2,130
4,474
7,172
6,686
Population characteristics
Enrollees with combat-related conditions
e
f
Enrollees with non-combat-related conditions
g
Enrollees with conditions not classified as either combat- or non-combat-related
Referrals
Total number of servicemembers and veterans referred to the program by
h
military treatment facilities
Source: GAO analysis of OEF/OIF/OND Care Management Program data.
a
According to OEF/OIF/OND Care Management Program officials, 2008 and 2009 data only include
severely wounded, ill, and injured because the database only tracked this subpopulation of the
program, which was the initial focus of the program’s efforts. This population included, for example,
those with severe burns, amputations, spinal cord injuries, or blindness, or more than one of these.
Soon after the program was initiated, the Department of Veterans Affairs found that people returning
from the conflicts in Iraq and Afghanistan required additional support, regardless of the severity of
their injuries or illnesses. Therefore, policy was changed and the OEF/OIF/OND Care Management
Program began tracking data on all those receiving case management services through their
program.
b
Total enrollment includes those who serve or served in National Guard and Reserve Components.
c
The OEF/OIF/OND Care Management Program primarily serves veterans. Some servicemembers
who are receiving treatment through a VA facility may also be enrolled in the program.
d
Others include enrollees with unknown military status.
e
Includes enrollees with battle injuries. According to OEF/OIF/OND Care Management Program
officials, battle injuries are injuries sustained while in combat, such as a wound from an improvised
explosive device.
f
Includes enrollees with nonbattle injuries. According to OEF/OIF/OND Care Management Program
officials, nonbattle injuries can include injuries sustained in a combat zone that are not directly related
to combat.
g
Includes enrollees with illnesses that may be classified as either combat-related or non-combatrelated. According to OEF/OIF/OND Care Management Program officials, the program tracks whether
an enrollee’s condition is a battle injury or a nonbattle injury, but not whether an illness is related to
combat.
h
According to OEF/OIF/OND Care Management Program officials, servicemembers and veterans are
either referred to the program by a military treatment facility or are screened into the program when a
servicemember or veteran initially seeks VA services at a VA treatment facility.
Page 71
GAO-13-5 Recovering Servicemembers and Veterans
Appendix I: Enrollment and Populations for
Select Department of Defense and Department
of Veterans Affairs Programs
FRCP
The FRCP was established in January 2008. Developed as a joint
program by DOD and VA, but administered by VA, the program was
designed to provide care coordination services to servicemembers and
veterans who were “severely” wounded, ill, and injured after September
11, 2001. (See table 13.) The program uses federal recovery coordinators
to monitor and coordinate clinical services, including facilitating and
coordinating medical appointments, and nonclinical services, such as
providing assistance with obtaining financial benefits or special
accommodations, needed by program enrollees and their families.
Federal recovery coordinators serve as the single point of contact among
all of the case managers of DOD, VA, and other governmental and
private case management programs that provide services directly to
servicemembers and veterans.
Page 72
GAO-13-5 Recovering Servicemembers and Veterans
Appendix I: Enrollment and Populations for
Select Department of Defense and Department
of Veterans Affairs Programs
Table 13: Federal Recovery Coordination Program (FRCP) Enrollment Populations and Characteristics, Fiscal Years 2008
through 2011
Fiscal year
2008
2009
2010
2011
Program enrollment for the FRCP
Total enrollment
Servicemembers
National Guard
a
177
522
823
1,022
132
325
394
573
11
51
84
87
7
30
45
63
43
194
429
449
2
3
0
0
Enrollees with combat-related conditions
ND
ND
ND
ND
Enrollees with non-combat-related conditions
ND
ND
ND
ND
Enrollees with conditions not classified as either combat- or non-combat-related
ND
ND
ND
ND
179
257
268
362
Servicemembers referred and enrolled in the program
132
194
222
293
Servicemembers referred and assisted, but not enrolled in the program
ND
ND
ND
ND
Servicemembers referred but not enrolled in or assisted by the program
47
63
46
68
44
171
165
119
Reservists
a
Veterans
Others
Population characteristics
Referrals and assists
Total number of servicemembers referred to the program
Total number of veterans referred to the program
Veterans referred and enrolled in the program
43
155
150
66
Veterans referred and assisted, but not enrolled in the program
ND
ND
ND
ND
Veterans referred but not enrolled in or assisted by the program
1
16
15
53
Legend: ND indicates that no data are available.
Source: GAO analysis of FRCP data.
a
According to an FRCP official, the total number of servicemembers who are active duty cannot be
delineated because the National Guard and Reservist numbers are descriptive data points and do not
designate whether the enrollee is active duty or veteran. In addition, not all National Guard and
Reservists are included in the data due to database limitations that have since been resolved.
Page 73
GAO-13-5 Recovering Servicemembers and Veterans
Appendix I: Enrollment and Populations for
Select Department of Defense and Department
of Veterans Affairs Programs
Referral Information
Tracked by DOD and
VA Case Management
and Care
Coordination
Programs
DOD and VA case management and care coordination programs
primarily identify servicemembers and veterans who may be eligible for
enrollment through referrals. Tracking referral information, including the
number of those who were referred and enrolled or not enrolled in the
program, may indicate whether the programs are identifying those who
could benefit from their services. However, fewer than half of the DOD
and VA case management and care coordination programs that we
reviewed track this type of referral information. (See table 14.)
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GAO-13-5 Recovering Servicemembers and Veterans
Appendix I: Enrollment and Populations for
Select Department of Defense and Department
of Veterans Affairs Programs
Table 14: Referral Information Routinely Tracked by DOD and VA Case Management and Care Coordination Programs
Referral information
routinely tracked
Program
Types of referral information tracked, if any
Army
Army Warrior Care and Transition Program:
Warrior Transition Units and CommunityBased Warrior Transition Units
√
Referral sources for program enrollees
Army Warrior Care and Transition Program:
Army Wounded Warrior Program
√
Total number of referrals made to the program
Number of those referred to the program who were
enrolled into the program
Number of those referred to the program who were
enrolled and provided short-term assistance by the
program, but who were later found ineligible for the
program and disenrolled
Number of those referred to the program who were not
enrolled into the program
a
Total number of referrals made to the program
Number of those referred to the program who were
enrolled into the program
Number of those referred to the program who were
provided short-term assistance by the program, but not
enrolled
Number of those referred to the program who were not
enrolled into the program or provided short-term
assistance by the program
Navy/Coast Guard
Navy Safe Harbor Program
√
Air Force
Air Force Wounded Warrior Program
According to Air Force Wounded Warrior Program
officials, since the program only serves servicemembers
with combat-related conditions, most referrals come
from casualty reports and the disability evaluation
process, where it is determined whether a
servicemember’s wound, illness, or injury is combatrelated.
Air Force Recovery Care Program
None
Marine Corps
Marine Corps Wounded Warrior Regiment
According to a Marine Corps Wounded Warrior
Regiment official, although a policy exists requiring
referral information to be collected, the policy was not
b
always enforced.
United States Special Operations Command
Page 75
GAO-13-5 Recovering Servicemembers and Veterans
Appendix I: Enrollment and Populations for
Select Department of Defense and Department
of Veterans Affairs Programs
Referral information
routinely tracked
Program
United States Special Operations
Command’s Care Coalition
Types of referral information tracked, if any
According to a United States Special Operations
Command’s Care Coalition official, the program does
not track referral information because there is no field in
its database to track this information. However,
according to this official, the program is able to access
this information from the individual military services.
Department of Veterans Affairs
Operation Enduring Freedom/Operation Iraqi
Freedom/Operation New Dawn Care
Management Program
√
Total number of referrals made to the program from
military treatment facilities
Federal Recovery Coordination Program
√
Total number of referrals made to the program
Number of those referred to the program who were
enrolled into the program
Number of those referred to the program who were
provided short-term assistance by the program, but not
enrolled
Number of those referred to the program who are not
enrolled into the program or provided short-term
assistance by the program
Source: GAO analysis of DOD and VA data.
a
According to a Navy Safe Harbor Program official, the database used to track referral information did
not capture accurate data until it was upgraded in 2010.
b
According to a Marine Corps Wounded Warrior Program official, as of fiscal year 2012, data on
referral information are routinely collected.
Page 76
GAO-13-5 Recovering Servicemembers and Veterans
Appendix II: Medical Category Assignment
Process for Care Coordination Programs
Appendix II: Medical Category Assignment
Process for Care Coordination Programs
The Senior Oversight Committee intended for the Federal Recovery
Coordination Program (FRCP) and the Recovery Coordination Program
(RCP) to be complementary programs, specifically identifying which
population of wounded, ill, and injured servicemembers would be
assigned to the two programs. On the basis of work done for the
committee, the Department of Defense (DOD) sent a report to
congressional committees in 2008 outlining a medical category
assignment process based on the severity of each servicemember’s
medical condition, along with input from the servicemember and his or her
unit commander, to determine whether servicemembers would be
directed either to the FRCP or to the RCP programs for care coordination
services.
In concept, the medical category assignment process would have
resulted in wounded, injured, or ill servicemembers being assigned to one
of three categories. Servicemembers designated as Category 1 were
those who were found to have mild injury or illness, who were expected to
return to duty in less than 180 days of medical treatment, and primarily
received local outpatient and short-term inpatient treatment and
rehabilitation. Servicemembers designated as Category 2 were those with
serious injury or illness, who were unlikely to return to duty in less than
180 days, and may be medically separated from the military. 1
Servicemembers designated as Category 3 were those with severe injury
or illness, who were highly unlikely to return to duty, and were most likely
to be medically separated from the military. The category designation was
intended to be used to determine whether the recovering servicemember
was subsequently referred to a care coordination program, in that
Category 1 servicemembers would not be referred to a care coordination
program, unless their medical or psychological conditions worsen;
Category 2 servicemembers would be referred to the RCP; and
Category 3 servicemembers would be referred to the FRCP. (See fig. 3.)
1
DOD subsequently modified the 180-day criteria to “within a time specified by his or her
military department” to accommodate different standards used by the Marine Corps and
the Army.
Page 77
GAO-13-5 Recovering Servicemembers and Veterans
Appendix II: Medical Category Assignment
Process for Care Coordination Programs
Figure 3: The Department of Defense’s Vision of the Assignment Process for the Recovery Coordination Program and the
Federal Recovery Coordination Program
Note: In this figure, solid arrows indicate typical or expected results and dashed arrows indicate
alternative, but possible, outcomes.
Page 78
GAO-13-5 Recovering Servicemembers and Veterans
Appendix III: Comments from the
Department of Defense
Appendix III: Comments from the Department
of Defense
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GAO-13-5 Recovering Servicemembers and Veterans
Appendix III: Comments from the Department
of Defense
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GAO-13-5 Recovering Servicemembers and Veterans
Appendix III: Comments from the Department
of Defense
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GAO-13-5 Recovering Servicemembers and Veterans
Appendix III: Comments from the Department
of Defense
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GAO-13-5 Recovering Servicemembers and Veterans
Appendix III: Comments from the Department
of Defense
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GAO-13-5 Recovering Servicemembers and Veterans
Appendix III: Comments from the Department
of Defense
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GAO-13-5 Recovering Servicemembers and Veterans
Appendix IV: Comments from the
Department of Veterans Affairs
Appendix IV: Comments from the Department
of Veterans Affairs
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GAO-13-5 Recovering Servicemembers and Veterans
Appendix IV: Comments from the Department
of Veterans Affairs
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GAO-13-5 Recovering Servicemembers and Veterans
Appendix IV: Comments from the Department
of Veterans Affairs
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GAO-13-5 Recovering Servicemembers and Veterans
Appendix IV: Comments from the Department
of Veterans Affairs
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GAO-13-5 Recovering Servicemembers and Veterans
Appendix IV: Comments from the Department
of Veterans Affairs
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GAO-13-5 Recovering Servicemembers and Veterans
Appendix IV: Comments from the Department
of Veterans Affairs
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GAO-13-5 Recovering Servicemembers and Veterans
Appendix IV: Comments from the Department
of Veterans Affairs
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GAO-13-5 Recovering Servicemembers and Veterans
Appendix V: GAO Contact and Staff
Acknowledgments
Appendix V: GAO Contact and Staff
Acknowledgments
GAO Contact
Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov
Staff
Acknowledgments
In addition to the contact name above, Bonnie Anderson, Assistant
Director; Mark Bird, Assistant Director; Michele Grgich, Assistant Director;
Jennie Apter; Frederick Caison; Heather Collins; Dan Concepcion;
Melissa Jaynes; Deitra Lee; Mariel Lifshitz; Lisa Motley; Elise Pressma;
and Greg Whitney made key contributions to this report.
Page 92
GAO-13-5 Recovering Servicemembers and Veterans
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